2007 Our Lady Of the Lake Cancer Annual Report

2007 Annual Report

ESOPHAGEAL CANCER

The Cancer Program of Our Lady of the Lake and Mary Bird Perkins 1

Chairman’s Letter On behalf of the Cancer Committee of the Cancer Program of Our Lady of the Lake (OLOL) and Mary Bird Perkins (MBP), I am pleased to present the 2006 Cancer Annual Report. On the pages that follow, you will read about recent highlights of the Cancer Program, as well as a ten-year study on esophageal cancer.

During 2006, the Cancer Program accomplished many clinical, programmatic, quality improvement and community outreach goals focused on the needs of cancer patients and the community at large.

The Cancer Program of Our Lady of the Lake and Mary Bird Perkins is an approved program of the American College of Surgeons (ACoS) Commission on Cancer (CoC).

The CoC is dedicated to improving survival and quality of life for cancer patients through best practice standards, prevention, research, education and quality of care initiatives. Only facilities that have voluntarily committed to provide the best in cancer care and comply with CoC established standards receive approval.

Meeting patients’ needs is the primary focal point of the Cancer Committee as it works to ensure a seamless approach to comprehensive cancer care. For many years, the Cancer Program of Our Lady of the Lake and Mary Bird Perkins has recruited top-notch medical professionals, instituted quality clinical pathways and acquired leading-edge technology so Louisianians can stay close to home and receive state-ofthe-art cancer treatment.

In addition, under the direction of the Cancer Committee, the Cancer Program continued to increase public awareness for prevention and early detection by providing free cancer screenings to the medically underserved. The Cancer Program increased its quantity of breast, colorectal, prostate and skin cancer screenings during nationallyrecognized cancer awareness months. Overall, the Cancer Program screened over 4,500 people at 122 free cancer screenings.

Last, but certainly not least, I am pleased to report that the Cancer Program of Our Lady of the Lake and Mary Bird Perkins was one of 14 community-based cancer programs in the country selected to participate in the National Cancer Institute Community Cancer Centers Program (NCCCP) pilot. The aims of the pilot are profound and include bringing more Americans in contact with high-quality, community-based cancer care, increasing participation in clinical trials, reducing cancer healthcare disparities and improving information sharing among community cancer programs. We look forward to participating in the important NCCCP initiative and are honored to join the elite group of hospitals and centers dedicated to improving the delivery of community-based cancer care in the United States.

Sincerely,

David S. Hanson, MD

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2006 Cancer Committee The Cancer Committee is a multidisciplinary organization responsible for planning, initiating, implementing, evaluating and improving all cancer-related activities. The Cancer Committee maintains an exemplary cancer program to benefit all patients.

The committee consists of physicians from specialties involved in cancer treatment and representatives from MBPCC and OLOL. PHYSICIANS

HEALTHCARE PROFESSIONALS

David S. Hanson, MD Hematology/Oncology Cancer Committee Chairman

Reverend Mark Adams OLOL Chaplain

David A. Boudreaux, MD Pathology Annual Report Committee Chairman PCE Subcommittee Chairman Tumor Registry Advisor ACoS Cancer Liaison Physician

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Kathy Babin, CTR OLOL Cancer Registry Tandra Davison, BSIE, CPHQ OLOL Performance Improvement Jennifer Blackman, MS, CCRP OLOL Manager of Clinical Research

M. Giles Fort III, MD Gynecological Oncology

Susan Finley, RN, OCN MBPCC Clinical Research Coordinator

Sheldon A. Johnson, MD Radiation Oncology

Kevin Guidry, MHA OLOL Cancer Center, Administrator

Jeffrey Littleton, MD General Surgery

Nicole Magee, CTR MBPCC Cancer Registry Director

Ryan Majoria, MD Radiology

Lori McCallum, MEd, CTR MBPCC Executive Director, C.A.R.E. Network

Gerald P. Miletello, MD Hematology/Oncology

Charmaine Mosby, RHIA OLOL Cancer Registry Manager

Susan E. Nelson, MD Gerontology

Charles W. Mouton, RD, LDN OLOL Dietitian

Stanley Peters, MD Otolaryngology

Jacqueline O’Neill, LCSW OLOL Cancer Liaison

Ronald Radzikowski, MD Internal Medicine OLOL Vice President of Medical Affairs Ex-Officio Member

Salli Phillips, LCSW, OSW-C MBPCC Social Worker

Brian W. Webb, MD Pathology

Brenda Truxillo, RN, LRT MBPCC Vice President, Radiation Oncology

Gena Skelton, RN, BSN OLOL Cancer Center Nurse Manager

Cancer Liaison physician’s Report The Cancer Liaison Physician Program was established in 1963 by the Commission on Cancer (CoC) of the American College of Surgeons. As an ACoS multidisciplinary program, the CoC is dedicated to decreasing morbidity and mortality from cancer through education, standard setting and monitoring of the quality of care.

Cancer Liaison Physicians (CLP) serve as links between the CoC and the hospitals they represent, manage clinically-related cancer activities within their local institutions and partner with local community agencies, such as the American Cancer Society (ACS), to accomplish community outreach goals regarding education, early detection and prevention of cancer.

This year marks my first year as CLP for the Cancer Program, taking over for my capable colleague David A. Boudreaux, MD, who has done such an admirable job for the last several years.

To better understand the responsibilities of a CLP, I have participated in two CoCsponsored web conferences titled The Role of the Cancer Liaison Physician and American Cancer Society: Resources and Services. I have also attended the CoC Annual Meeting and the Cancer Liaison Program Breakfast Meeting, both held in New Orleans.

With regard to my responsibilities specific to the Cancer Program, I participate in quarterly meetings of the Cancer Committee by reporting upcoming activities and initiatives of the ACS. I also report on the quality assurance studies I personally perform regarding the use of College of American Pathologists (CAP) checklists on all pathology reports with a cancer diagnosis. This has led to the initial steps in standardizing pathology reports and cancer diagnoses across different institutions within the community to ensure completeness and accuracy.

Other activities I have been involved with include reviewing our Patient Care Evaluation (PCE) study regarding esophageal cancer as well as attending preliminary meetings on developing a biospecimen repository (“tissue bank�), one of the initiatives from the National Cancer Institute Community Cancer Centers Program (NCCCP) pilot.

I look forward to working with local and national organizations to facilitate communication and collaboration in the years ahead.

Sincerely,

Brian Webb, MD

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Cancer-related Services

OLOL

MBPCC

TREATMENT

Medical Oncology

Chemotherapy l

Hormonal/Antihormonal Therapy l

Immunotherapy l

Infusion Therapy l

Peripheral Stem Cell Transplantation l

Radiation Oncology

Radiation Therapy

External Beam Radiotherapy l

High Dose Rate Brachytherapy (HDR) l

Image Guided Radiation Therapy (IGRT) l

Intensity Modulated Radiation Therapy (IMRT) l

Prostate Seed Implants l l

SirSpheres l l

Stereotactic Radiosurgery l

Treatment Planning

Computerized Axial Tomography (CT) l l

Image Fusion (CT, MRI, PET) l l

Medical Physics/Dosimetry l

Positron Emission Tomography (PET) l l

Virtual Simulation l

Dental Oncology l l

Surgical Oncology l

Support Services

CancerFit l

Enterostomal Therapy l

Nutritional Support l l

Occupational, Physical and Speech Therapies l

Pastoral Care l

Respiratory Therapy l

Social Services l l

Other Services

Lymphedema Prevention Clinics l

Pain Management l l

Patient Transportation l

EDUCATION

Professional Education

Allied Health Cancer Grand Rounds l

Continuing Education (CE) l l

Continuing Medical Education (CME) l l

Graduate Medical Education (GME) l l

Medical Library l l

Community Education

Cancer Resource Call Center l l

Cancer Screenings l l

Community Library l l

Community Outreach l l

Elderly Services l

Speakers Bureau l l CASE MANAGEMENT

Tumor Conferences RESEARCH

Clinical Research

Tumor Registry

4

l

l

l

l

l

l

Tumor Conferences Multidisciplinary treatment planning conferences are

held weekly to improve the care of patients with cancer. The cases of patients from the Cancer Program are selected for presentation and discussion based on the case complexity, unusual presentation of disease or special interest. Physician representatives from appropriate disciplines attend and participate in the conference.

In March 2006, the Cancer Committee presented a facility-wide didactic CME conference titled Incorporating Genomics in the Management of Early Stage Breast Cancer by Virginia Kaklamani, MD, DSc. During 2006, 162 cases were presented at the standard weekly tumor conference. The cases reviewed included neoplasms of the following types and sites.

Blood/Bone Marrow 7 Brain/Nervous System 2 Breast

21

Digestive System

50

Endocrine 2 Lymphatic System

11

Male Genital 8 Oral Cavity/Pharynx 2 Respiratory/Intrathoracic

25

Skin 7 Soft Tissue

11

Unknown Primary 9 Urinary Tract 7

To schedule cases for presentation, physicians may call Dianne Griffin at (225) 215-1238.

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An Overview: Esophageal Cancer Esophageal cancer is a disease in which a

malignant tumor arises from the tissues lining the esophagus.

Located behind the trachea, the esophagus is a 10inch-long, hollow, muscular tube that carries food and liquids from the mouth/pharynx to the stomach; it is divided into upper (cervical), middle (thoracic) and lower (abdominal) segments. The inner lining of the esophagus (the mucosa) is normally comprised of flattened squamous epithelium. Between the mucosa and the muscular wall, there are submucosal glands that keep the passageway moist and make swallowing easier.

A rich network of blood vessels and lymphatics runs the length of the esophagus with extensive interconnections, making the course of metastatic spread from esophageal cancer somewhat unpredictable. Tumors from the upper esophagus typically spread to the cervical and superior mediastinal lymph nodes. Tumors from the lower esophagus often spread to the lower mediastinal and abdominal lymph nodes. The most common extranodal sites of metastasis are the liver and lung. Unlike the rest of the gastrointestinal tract, the outer surface of the esophagus is not surrounded by a serosa (a thin layer of mesothelial cells); so the adjacent mediastinum is susceptible to direct involvement by a tumor invading through the esophageal wall.

Esophageal cancer is divided into two major histologic types. Squamous cell carcinomas usually arise from the cells that line the upper and middle parts of the esophagus. Adenocarcinomas typically involve the lower esophagus and arise within mucosa that has been damaged, usually by gastroesophageal reflux disease (GERD) and has undergone metaplastic change to a more intestinal type glandular epithelium (Barrett’s esophagus). Adenocarcinomas may also arise from the submucosal glands within the esophagus. Other types of tumors such as melanomas, sarcomas and lymphomas comprise only a very small fraction of esophageal malignancies.

The incidence of esophageal cancer fluctuates dramatically throughout the world and has the largest variability of any known malignancy. Esophageal cancer is the third most common tumor of the digestive tract and the seventh leading cause of cancer death worldwide. Incidence of esophageal carcinoma can be as high as 30 to 800 cases per 100,000 persons in particular areas of northern Iran, areas of southern Russia and northern China. Unlike the United States, squamous cell carcinoma is responsible for 95 percent of all esophageal cancer worldwide.

The epidemiology of esophageal cancer has changed markedly over the past several decades in the United

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States. Until the 1970s, squamous cell carcinoma accounted for more than 90 percent of esophageal cancer, which was lodged in the mid esophagus and commonly affected mostly African-American men with a long history of smoking and alcohol consumption.

Over the last two decades, adenocarcinoma of the lower esophagus related to Barrett’s esophagus has the fastest growing incidence rate of all cancers. Currently, it accounts for over half of the 15,000 new cases of esophageal cancer diagnosed each year (approximately three to six cases per 100,000 persons).

RISK FACTORS Both types of esophageal carcinoma are more common in adults over age 60 and develop more often in men than in women. Tobacco use, whether by smoking or using smokeless tobacco, also increases the risk of both types of carcinoma–particularly squamous cell carcinoma. Chronic and/or heavy use of alcohol is a major risk factor for squamous cell esophageal cancer, and people who use both alcohol and tobacco have an especially high risk. Other risks for squamous cell carcinoma include low intake of fruits and vegetables, infection with human papilloma virus, achalasia (a benign esophageal muscular disease) and chronic scarring of the esophagus due to swallowing lye or other caustic substances.

The most significant risk factor for esophageal adenocarcinoma is the development of Barrett’s esophagus secondary to chronic GERD. Tobacco use, obesity and poor diet may also play a role by contributing to the development or persistence of GERD. A genetic predisposition for esophageal carcinoma has been suggested since these cancers have been found to cluster within some families; however, this observation may be related to common environmental factors. Studies investigating the molecular biology of esophageal carcinoma have yielded several potential molecular alterations involved in its pathogenesis that soon may be applied to the diagnosis, prognosis and treatment of this devastating disease.

CLINICAL FINDINGS Dysphagia (difficulty swallowing), which progresses from solids to liquids, is the most common presenting symptom. Weight loss is the second most common symptom and occurs in more than 50 percent of people with esophageal carcinoma. Pain can be felt in the epigastric or retrosternal area and over bony structures, representing a sign of metastatic disease. Hoarseness caused by invasion of the recurrent laryngeal nerve and respiratory symptoms related to invasion of the tracheobronchial tree by the tumor are both signs of unresectability.

SCREENING There are no early detection tests used in the United States to screen the general population for esophageal cancer. However, people with Barrett’s esophagus

or other risk factors are followed closely with esophagogastroduodenoscopy (EGD, upper endoscopy); this involves passing a flexible tube down the esophagus and visualizing the wall. Then, the biopsies are examined histologically for abnormal changes.

Dysplasia in Barrett’s esophagus represents an early pre-malignant alteration of the columnar epithelium that may progress to invasive adenocarcinoma. While patients with low-grade dysplasia may be followed by endoscopic surveillance, the detection of high-grade dysplasia often prompts definitive treatment to prevent the progression to carcinoma. Dysplastic epithelium in Barrett’s esophagus often has no distinguishing endoscopic features, and numerous random biopsy specimens are taken for histologic examination.

Several new techniques have been proposed to highlight dysplastic areas for targeted sampling during endoscopy, including chromoendoscopy, endosonography, optical coherence topography and fluorescence detection techniques; however, these remain in an investigational stage.

DIAGNOSIS/STAGING Occlusive tumors or strictures may be suspected by chest X-ray or with barium swallow. However, a definitive diagnosis is best made by endoscopic examination with biopsies of suspicious lesions, which are then evaluated by a pathologist for malignancy.

Additional testing estimates the extent of the disease (tumor stage). Computed tomography (CT) of the chest, abdomen and pelvis detect whether the cancer has spread to adjacent tissues or distant organs (especially liver and lymph nodes). CT scan sensitivity is limited by its ability to detect masses generally larger than one centimeter. Positron emission tomography (PET) scans estimate whether enlarged masses are metabolically active, indicating faster-growing cells characteristic of cancer. Esophageal endoscopic ultrasound (EUS) provides staging information regarding the level of tumor invasion and possible spread to regional lymph nodes.

TREATMENT Esophageal resection (esophagectomy) remains a crucial part of esophageal cancer treatment. It is used in the 20 to 30 percent of patients with high-grade dysplasia or small, less advanced (lower stage) cancers that are localized. If the tumor is larger but still localized, chemotherapy and/or radiotherapy may occasionally shrink the tumor to an operable size.

An esophagectomy can be performed by using either an abdominal/cervical approach (i.e., transhiatal esophagectomy, THE) or a thoracic approach (i.e., transthoracic esophagectomy, TTE). THE offers the advantage of avoiding a chest incision, which can prolong discomfort and further aggravate the condition of patients with compromised respiratory function.

Some authors question the validity of THE as a cancer operation because part of the surgery is not

performed under direct vision and fewer lymph nodes are removed compared to TTE. Yet, many retrospective and two prospective studies have shown no difference in survival between the operations, suggesting cancer stage at the time of surgery–not the type of operation– influences survival.

The use of laparoscopic or thoracoscopic techniques has revolutionized the treatment of benign esophageal disorders such as achalasia and GERD. When compared to open surgery, the hospital stay is shorter; the postoperative discomfort is reduced; and, the recovery time is much faster. Since these techniques reduce morbidity due to cardiac and respiratory complications, they soon may become standard in the treatment of esophageal cancer.

Laser therapy is the use of high-intensity light to destroy tumor cells; it affects only the treated area.

This therapy is recommended if the cancer cannot be removed surgically. The relief of a blockage can help reduce dysphagia and pain.

Photodynamic therapy (PDT), a type of laser therapy, involves the use of drugs that are absorbed by cancer cells. When exposed to a special light, the drugs become active and destroy the cancer cells. Both laser therapy and photodynamic therapy can provide effective palliation for superficial tumors and are not currently considered curative modalities.

Chemotherapy depends on the tumor type but tends to be cisplatin-based (or carboplatin or oxaliplatin) every three weeks with fluorouracil (5-FU) either continuously or every three weeks. In recent studies, the addition of epirubicin (ECF) was better than other comparable regimens in advanced nonresectable cancer.

Chemotherapy may be given after surgery (adjuvant, i.e., to reduce risk of recurrence), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. Ongoing trials compare various combinations of chemotherapy. For example, the Phase II/III REAL-2 trial compares four regimens containing ECF and either cisplatin or oxaliplatin and either continuously infused 5-FU or capecitabine.

Radiotherapy is given before, during or after chemotherapy or surgery and, sometimes, alone to control symptoms. In patients with localized disease with contra-indications to surgery, radical radiotherapy may be used with curative intent.

PROGNOSIS Esophageal cancer is a treatable disease and can be cured–if discovered in an early stage. In patients amenable to definitive treatment, the overall five-year survival rate ranges from five to 30 percent. Patients with severe dysplasia in distal esophageal Barrett’s mucosa often have in situ or even invasive cancer within the dysplastic area. Following resection, these patients usually have excellent prognoses.

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Figure 1: Year of Diagnosis Figure 1: Esophageal Cancer–Year of Diagnosis 18

During the past 10 years (1997 to 2006), there were 123 cases of esophageal carcinoma that were diagnosed and/or received initial therapy at OLOL or MBPCC.

Number of Cases Per Year

16 14 12

Although relatively few cases of esophageal carcinoma are diagnosed each year, there does appear to be a slight decline over this period that most likely reflects a local patient demographic shift rather than a decreasing incidence of esophageal carcinoma.

10 8 6 4 2 0 1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

n OLOL/MBPCC

Year of Diagnosis

Figure 2: Age at Diagnosis and Comparison with National Statistics Age

Number of cases

Percentage

0-29

1

0.8%

0.1%

30-39

1

0.8%

1.0%

40-49

10

8.1%

6.7%

50-59

28

22.8%

20.1%

60-69

32

26.0%

27.8%

70-79

37

30.1%

29.0%

80-89

13

10.6%

14.0%

90+

1

0.8%

1.3%

n OLOL/MBPCC 1997-2006 n NCDB 2000-2004

While esophageal carcinoma is typically diagnosed in patients between the fifth and seventh decades, our data revealed a broad age range. While the youngest patient was diagnosed at age 27, the oldest was age 93. Both had squamous cell carcinomas. Overall, our data closely parallel that of NCDB.

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Figure 3: Gender, Race and Comparison with National Statistics All Races Gender

Number

Percentage

Caucasian

African American

Other

Percentage

Percentage

Percentage

Male

96

78.0%

78.9%

54.5%

64.5%

22%

8.3%

1.6%

5.2%

Female

27

22.0%

21.1%

15.5%

17.3%

6.5%

3.3%

0.0%

1.5%

123

100.0%

100.0%

70.0%

81.8%

28.4%

11.6%

1.6%

6.6%

Total

n OLOL/MBPCC 1997-2006

n NCDB 2000-2004

Esophageal carcinoma is typically more common in men than in women with a reported male to female ratio of more than 3:1. Our local data show a similar ratio and closely parallel those of the NCBD. When looking at race, our local data show a greater percentage of esophageal carcinomas arising in African Americans (more than twice that seen in the national statistics), while other races appear underrepresented. This no doubt reflects the makeup of our local population.

Figure 4: Histopathologic Patterns

16 14

Number of Cases Per Year

12 10 n OLOL/MBPCC Squamous cell carcinoma Squamous cell carcinoma

8

Adenocarcinoma

n OLOL/MBPCC Adenocarcinoma

6 4 2 0

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Year of Diagnosis

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Figure 5: Histologic Patterns and Comparison with National Statistics Histologic type

Number of Cases

Carcinoma, NOS*

Percentage

0

0.0%

4.3%

Squamous Cell Carcinoma

68

55.3%

31.7%

Adenocarcinoma

52

42.3%

53.0%

All other types**

3

2.4%

11.0%

123

100.0%

100.0%

Total

n OLOL/MBPCC 1997-2006 n NCDB 2000-2004

* NOS~ not otherwise specified **Other histologic types include adenosquamous carcinoma and small cell carcinoma

Figure 6: Histologic Patterns, Race and Comparison with National Statistics

Histologic type

Caucasian

African American

Other

Percentage

Percentage

Percentage

Squamous cell carcinoma

39.5%

24.6%

91.4%

73.9%

100%

43.5%

Adenocarcinoma

59.3%

60.2%

2.9%

10.4%

0.0%

39.7%

Carcinoma, NOS

0.0%

4.4%

0.0%

3.9%

0.0%

5.2%

All other types

1.2%

10.8%

5.7%

11.8%

0.0%

11.6%

100.0%

100.0%

100.0%

100.0%

Total

100.0%

100.0%

n OLOL/MBPCC 1997-2006

n NCDB 2000-2004

As shown in Figures 4, 5 and 6, esophageal carcinoma is divided into two major histologic types—squamous cell carcinoma and adenocarcinoma. Despite the national trend of an increasing incidence of adenocarcinoma, our data reveal a higher percentage of squamous cell carcinoma, which may reflect a higher than average African American population at greater risk for squamous cell carcinoma. Another possibility is the presence of a higher incidence of known risk factors for squamous cell carcinoma (i.e., smoking and alcohol use) compared to the incidence of gastroesophageal reflux disease (GERD) and development of Barrett’s esophagus typically associated with adenocarcinoma.

Figure 7: American Joint Committee on Cancer (AJCC) Stage at Diagnosis and Comparison with National Statistics Stage

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Number of cases

Percentage

Stage 0

2

1.6%

2.4%

Stage I

16

13.0%

9.7%

Stage II

23

18.7%

19.8%

Stage III

15

12.2%

18.8%

Stage IV

28

22.8%

27.6%

Unknown

39

31.7%

21.7%

Total

123

100.0%

100.0%

Over the past 10 years (1997-2006), our local data for the distribution of esophageal carcinoma by the American Joint Committee on Cancer (AJCC) stage at diagnosis parallel the national statistics. n OLOL/MBPCC 1997-2006 n NCDB 2000-2004

Figure 9: Relative Five-Year Survival Rates and Comparison w 70%

Figure 8: Relative Five-Year Survival Rates and Comparison with National Statistics

60%

n OLOL/MBPCC 1997-2006

50%

Survival Rates

Esophageal carcinoma is one of the most lethal malignancies with an overall five-year survival rate of only 15 percent according to national statistics from the NCDB. While early detection significantly improves survival rates, it is notable that approximately one out of three patients diagnosed with even the lowest stage lesion (carcinoma in-situ or Stage 0) succumb to the disease within five years. Our local data reflect survival rates that closely parallel those of NCBD.

40%

OLOL/M NCDB 19

30% 20% 10% 0%

n NCDB 1996-2000

Stage 0

Stage I

Stage II

Stage III

Stage IV

Overall

Stage at Diagnosis

Figure 5: Treatment Modalities: First Course and Comparis on with National Statistics 40%

35%

Percentage of Cases

30%

25%

n OLOL/MBPCC 1997-2006

OLOL/MBPCC 1997-2006 NCDB 2000-2004 n NCDB 2000-2004

20%

15%

10%

5%

0%

Chem/Rad

Surg/Rad/Chem

Surg only

Rad only

Chem only

None

Treatment Modalities

Figure 9: Treatment Modalities: Entire First Course and Comparison with National Statistics Treatment for esophageal cancer depends greatly on the extent of the disease, i.e., clinical stage.

Lower stage tumors usually only require some form of surgical resection, while more advanced tumors usually necessitate multiple treatment modalities including surgery, chemotherapy and/or radiation therapy. Our local data reveal 59 percent of our patients initially received a combination of at least two treatment modalities compared to the national average of 44 percent. Single modality therapy was used less often compared to national averages, suggesting our patients may present with higher stage tumors at the time of initial treatment and thus require more aggressive treatment. The percentage of our local patient population opting for no treatment is comparable to that seen in the national statistics.

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OLOL Cancer Registry The Cancer Registry is a specialized data system designed

for the collection, management and analysis of demographic, diagnostic, treatment and staging data on cancer patients treated at OLOL. The Cancer Registry reference date is 1987, and it contains data on 36,965 cancer cases. All new cases identified are abstracted, coded and staged in accordance with guidelines set by the American College of Surgeons (ACoS), the National Cancer Institute’s Surveillance Epidemiology and End Results (SEER) program and the Louisiana Tumor Registry (LTR). High importance is placed on data quality using these guidelines, and a physician member of the Cancer Committee reviews a sample of the cases for quality assurance. Once part of the registry database, these cases are followed throughout the patient’s life. The OLOL Cancer Registry maintains a follow-up rate averaging 95 percent, which exceeds the ACoS minimum standard of 90 percent.

Of the 1,284 newly accessioned cases in 2006, 1,132 were analytic and 152 were non-analytic*. The top five sites treated were lung, prostate, colon, breast and Non-Hodgkin’s lymphoma.

The OLOL cancer registry maintains cancer data that are available for use by clinical and administrative staff at OLOL. All information collected is kept completely confidential. During 2006, the registry received requests for statistical reports including analytic studies, annual statistics, research activities, healthcare delivery and quality management studies. The registry also reported to the state cancer registry and the National Cancer Data Base (NCDB) and participated in the Facility Information Profile System (FIPS) on the American Cancer Society’s website www.cancer.org. *Analytic cases are those receiving all or part of the first course of therapy at OLOL within the first four months of diagnosis.

Non-analytic cases are those not seen within the first four months following diagnosis.

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OLOL 2006 Site Distribution Table Site Group All Sites Blood/Bone Marrow Leukemia Myeloma Other Hematopoietic Bone Brain Breast Digestive System Anus, Anal Canal, Anorectum Bile Duct Colon Esophagus Gallbladder Liver Pancreas Rectum & Rectosigmoid Small Intestine Stomach Digestive, Other Endocrine Thyroid Other Endocrine Female Genital Cervix Uteri Corpus Uteri Fallopian Tube Ovary Vagina Vulva Lymphatic System Hodgkin’s Disease Non-Hodgkin’s Lymphoma Male Genital Penis Prostate Testis Oral Cavity/Pharynx Gum Hypopharynx Lip Mouth, Floor of Mouth, Other & NOS Nasopharynx Nasal Cavity, Sinus, Ear Oropharynx Salivary Glands, Major Tongue Tonsil Other Nervous System Respiratory/Intrathoracic Larynx Lung/Bronchus, Non-Small Cell Lung/Bronchus, Small Cell Pleura Skin Melanoma of Skin Other Skin Cancer Soft Tissue Unknown or Ill-Defined Urinary Tract Bladder Kidney and Renal Pelvis Ureter Urethra

Total Cases 1284 72 37 27 8 3 55 81 282 1 2 132 12 6 8 35 52 11 22 1 20 18 2 22 2 4 1 11 1 3 83 11 72 154 3 147 4 37 1 2 1 5 3 6 2 1 11 5 15 262 26 200 34 2 29 27 2 11 26 132 58 69 3 2

Class A N/A 1132 152 51 21 29 8 17 10 5 3 3 0 52 3 55 26 253 29 1 0 2 0 119 13 10 2 5 1 8 0 32 3 46 6 11 0 18 4 1 0 18 2 17 1 1 1 17 5 2 0 2 2 1 0 8 3 1 0 3 0 71 12 9 2 62 10 144 10 3 0 138 9 3 1 32 5 1 0 1 1 1 0 5 0 2 1 5 1 1 1 1 0 10 1 5 0 14 1 238 24 18 8 186 14 32 2 2 0 26 3 24 3 2 0 11 0 23 3 124 8 53 5 66 3 3 0 2 0

Sex M 750 44 24 18 2 3 26 3 146 0 1 66 12 3 3 15 24 6 15 1 7 5 2 1 0 0 0 0 1 0 42 8 34 153 3 146 4 25 1 1 1 4 1 4 2 1 7 3 4 166 24 120 20 2 20 18 2 6 14 90 46 41 1 2

F 534 28 13 9 6 0 29 78 136 1 1 66 0 3 5 20 28 5 7 0 13 13 0 21 2 4 1 11 0 3 41 3 38 1 0 1 0 12 0 1 0 1 2 2 0 0 4 2 11 96 2 80 14 0 9 9 0 5 12 42 12 28 2 0

0 39 0 0 0 0 0 0 6 3 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 0 0 0 0 0 0 2 0 1 1 0 0 0 0 0 0 26 24 0 1 1

I 229 0 0 0 0 1 0 24 53 0 0 29 4 3 1 0 14 0 2 0 11 11 0 1 0 0 0 0 0 1 17 1 16 5 1 1 3 6 0 0 1 1 0 0 0 0 4 0 0 51 6 42 2 1 12 12 0 6 0 43 7 36 0 0

Stage II III 252 150 0 0 0 0 0 0 0 0 0 0 0 0 15 2 56 37 0 1 1 0 32 21 3 0 0 0 0 1 5 2 11 9 2 1 2 2 0 0 1 2 1 2 0 0 2 6 1 1 0 0 0 1 1 3 0 0 0 1 17 6 4 0 13 6 116 19 0 0 116 18 0 1 8 2 1 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 4 0 1 1 0 0 13 57 2 4 10 42 1 10 0 1 5 4 5 3 0 1 0 1 0 0 18 15 11 4 6 10 0 1 1 0

IV 250 0 0 0 0 1 0 7 73 0 0 27 2 1 2 22 9 2 8 0 3 3 0 4 0 0 0 3 1 0 29 4 25 1 0 1 0 13 0 1 0 2 2 2 1 1 1 3 0 101 6 77 18 0 1 1 0 1 0 16 4 11 1 0

Not App. 160 51 29 17 5 1 52 0 8 0 0 1 0 0 0 1 0 4 1 1 1 0 1 2 0 2 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 14 2 0 2 0 0 1 0 1 1 23 3 1 2 0 0

Unk. 52 0 0 0 0 0 0 1 23 0 1 6 1 1 4 2 3 2 3 0 0 0 0 2 0 0 0 1 0 1 2 0 2 3 1 2 0 2 0 0 0 0 0 1 0 0 1 0 0 12 0 12 0 0 3 3 0 1 0 3 2 1 0 0

NOS = Not Otherwise Specified A = Analytic N/A = Non-Analytic M = Male F = Female Not App. = Not Applicable Unk. = Unknown or unstaged

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MBPCC Cancer Registry In March of 2007, the cancer registry departments of OLOL

and MBPCC integrated services and became the Integrated Cancer Registry (ICR) of MBPCC. The ICR will streamline many of the existing functions such as the Cancer Annual Report, patient care studies, follow-up on shared cases, tumor conferences, quality improvement initiatives and case abstracting. In addition, the ICR will benefit from a consolidated database allowing shared cases of the two institutions to have the most complete and accurate data regarding diagnosis and treatment.

The Cancer Registry is an integral component of the Commission on Cancer (CoC) approved program and plays a vital role in the success of the program. The registry collects and analyzes demographic, diagnostic, treatment and staging data on cancer patients treated at MBPCC in Baton Rouge.

The MBPCC Cancer Registry reference date is 1989, and it contains data on 10,058 cancer cases. All new cases identified are abstracted, coded and staged in accordance with guidelines set by the American College of Surgeons (ACoS), the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program and the Louisiana Tumor Registry (LTR). High importance is placed on data quality using these guidelines and a radiation oncologist reviews a sample of the cases for quality assurance. Once part of the registry database, these cases are followed throughout the patient’s life. MBPCC Cancer Registry maintains a follow-up rate averaging 95 percent, exceeding the ACoS minimum standard of 90 percent.

Of the newly accessioned cases in 2006, 672 were analytic and 117 were non-analytic*. The top five sites treated were breast, lung, prostate, brain and colorectal.

The registry maintains cancer data that is available for use by clinical and administrative staff at MBPCC. All information collected is kept confidential in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations. During 2006, the registry received requests for statistical reports including analytic studies, annual statistics, research activities and quality management studies. The registry participated in the National Cancer Data Base (NCDB) Annual Call for Data and participated in the Facility Information Profile System (FIPS) initiative on the American Cancer Society’s website www.cancer.org. *Analytic cases are those receiving all or part of the first course of therapy at MBPCC within the first four months of diagnosis.

Non-analytic cases are those not seen within the first four months following diagnosis.

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MBPCC 2006 Site Distribution Table Class Site Group All Sites Blood/Bone Marrow Leukemia Myeloma Brain Breast Digestive System Anus, Anal Canal, Anorectum Bile Duct Colon Esophagus Liver Pancreas Rectum & Rectosigmoid Small Intestine Stomach Endocrine Thyroid Other Endocrine Female Genital Cervix Uteri Corpus Uteri Ovary Vagina Lymphatic System Hodgkin’s Disease Non-Hodgkin’s Lymphoma Male Genital Prostate Testis Oral Cavity/Pharynx Gum Hypopharynx Lip Mouth, Floor of Mouth, Other & NOS Nasopharynx Nasal Cavity, Sinus, Ear Oropharynx Salivary Glands, Major Tongue Tonsil Respiratory/Intrathoracic Larynx Lung/Bronchus, Non-Small Cell Lung/Bronchus, Small Cell Pleura Skin Melanoma of Skin Other Skin Cancer Soft Tissue Unknown or Ill-Defined Urinary Tract Bladder Kidney and Renal Pelvis

Sex

Stage

Total Cases

A

N/A

M

F

0

I

II

III

IV

Not App.

Unk.

789 11 2 9 35 171 73 4 1 7 7 1 13 29 2 9 4 1 3 37 22 13 1 1 21 3 18 134 128 6 46 2 4 1 5 6 5 2 2 11 8 210 25 150 33 2 11 6 5 3 13 20 12 8

672 8 0 8 31 157 58 3 1 1 7 0 12 23 2 9 2 1 1 34 20 12 1 1 13 2 11 108 102 6 46 2 4 1 5 6 5 2 2 11 8 183 25 131 26 1 5 1 4 2 13 12 8 4

117 3 2 1 4 14 15 1 0 6 0 1 1 6 0 0 2 0 2 3 2 1 0 0 8 1 7 26 26 0 0 0 0 0 0 0 0 0 0 0 0 27 0 19 7 1 6 5 1 1 0 8 4 4

412 4 2 2 16 0 45 2 1 4 6 0 7 18 2 5 2 1 1 0 0 0 0 0 12 0 12 134 128 6 33 1 4 0 3 5 3 1 2 10 4 135 23 92 18 2 8 6 2 2 8 13 9 4

377 7 0 7 19 171 28 2 0 3 1 1 6 11 0 4 2 0 2 37 22 13 1 1 9 3 6 0 0 0 13 1 0 1 2 1 2 1 0 1 4 75 2 58 15 0 3 0 3 1 5 7 3 4

20 0 0 0 0 18 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0

109 0 0 0 0 63 3 0 0 0 0 0 2 0 0 1 0 0 0 9 3 6 0 0 3 0 3 5 0 5 2 0 0 0 1 1 0 0 0 0 0 20 6 11 3 0 2 1 1 2 0 0 0 0

183 0 0 0 0 46 18 1 0 0 3 0 2 11 0 1 0 0 0 7 4 3 0 0 4 1 3 85 85 0 8 1 2 0 1 1 0 0 0 3 0 11 2 8 1 0 1 0 1 0 0 3 3 0

131 0 0 0 0 19 19 2 0 0 3 0 4 6 1 3 0 0 0 11 9 2 0 0 2 1 1 14 13 1 6 0 0 1 0 1 1 0 0 2 1 56 3 43 9 1 1 0 1 0 0 3 3 0

158 0 0 0 0 10 11 0 0 1 1 0 1 4 1 3 1 1 0 4 3 0 1 0 4 0 4 4 4 0 28 1 2 0 3 3 3 2 2 6 6 91 13 65 13 0 0 0 0 0 0 5 1 4

56 8 0 8 31 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 13 0 0 0

15 0 0 0 0 1 7 0 1 0 0 0 3 2 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 4 0 4 0 0 0 0 0 0 0 1 1 0

NOS = Not Otherwise Specified A = Analytic N/A = Non-Analytic M = Male F = Female Not App. = Not Applicable Unk. = Unknown or unstaged

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The Cancer Program of Our Lady of the Lake and Mary Bird Perkins The Cancer Program of OLOL and MBP coordinates the entire continuum of cancer care. Surgical and medical oncology are available at OLOL and radiation oncology is available at MBP. The Cancer Program is the most comprehensive cancer program in the Baton Rouge area offering patients the convenience of receiving high-quality, advanced cancer care in one location close to home. The Cancer Program has been accredited since 1992 by the American College of Surgeons (ACoS)–the goldstandard for community-based cancer care. For over a century combined, the Cancer Program has delivered–with compassion and excellence–the most advanced cancer care available to Louisiana’s citizens.

The Cancer Program provides nearly 42,000 cancer treatments and accessions over 2,200 new cancer cases annually, which is approximately 11 percent of new cases in the state each year. The Cancer Program addresses care for a broad variety of primary sites, with the most common seen being lung, breast, digestive system, prostate and urinary cancers.

Approximately 15 percent of newly accessioned cases are indigent patients. The gender distribution of new cases is 55 percent male and 45 percent female. Almost 20 percent of cases present at late stages, which is consistent with Louisiana’s high cancer mortality rates and fuels the commitment for outreach and improvement found within the Cancer Program and its medical staff. Of the 41,986 treatments delivered, 16 percent of those treatments were to indigent patients.

The Cancer Program is the largest and most advanced cancer program in Louisiana with a steadfast dedication to finding cancer and fighting it with our extensive resources and unique clinical expertise. Our program proves daily that area residents do not have to leave family and friends behind to find innovative, world-class treatment.

The Cancer Program has been recognized nationally for its excellence in cancer care. It has been selected by the National Cancer Institute (NCI) as one of only 14 sites in the country, and the only one in the Gulf South, to participate in its new and prestigious National Community Cancer Centers Program (NCCCP) pilot.

The Cancer Program of OLOL and MBP was chosen based on its ability and experience in conducting clinical trials and providing leadership and healthcare outreach in the communities it serves. A successful pilot will lead to the nationwide launch of the NCCCP in 2010.

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17

5000 Hennessy Boulevard

4950 Essen Lane

Baton Rouge, LA 70808-4398

Baton Rouge, LA 70809-3432

(225) 765-8879

(225) 767-0847 or (225) 215-1100

ololrmc.com

marybird.org