The Cancer Program of Our Lady of the Lake and Mary Bird Perkins 2010 Annual Report

CANCER PROGRAM OF OUR LADY OF THE LAKE AND MARY BIRD PERKINS

2010 ANNUAL REPORT

2009 Cancer Committee

The Cancer Committee is a multidisciplinary team responsible for planning, initiating and assessing 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 other representatives from Our Lady of the Lake Regional Medical Center (OLOL) and Mary Bird Perkins (MBP).

PHYSICIANS

HEALTHCARE PROFESSIONALS

David S. Hanson, MD

Reverend Mark Adams

Hematology/Oncology Cancer Committee Chairman Tumor Conference Coordinator

Brian W. Webb, MD

Pathology Annual Report Committee Chairman PCE Subcommittee Chairman Cancer Registry Advisor ACoS C0C Liaison Physician Community Outreach Coordinator

Mitchell Berger, MD Medical Director

Alec A. Hirsch, MD General Surgery

Sheldon A. Johnson, MD Radiation Oncology

Mark Kantrow, MD Palliative Care

Ryan Majoria, MD

Diagnostic/Interventional Radiology

Gerald Miletello, MD Medical Oncology

Mark Posner, MD Urology

M. Patrick Stagg, MD Medical Oncology

Brad Vincent, MD Pulmonology

Chaplain

Sheila Alexander, CTR Cancer Registrar

Donna Bryant, MSN, OCN, ANP-C, CCRC Executive Director, Clinical Research

Melissa DuBois, CTR

Cancer Program Coordinator

Renea Austin-Duffin, MPA

Vice President, Cancer Programs

Terry Freeman, CTR Cancer Registrar

Kevin Guidry, MHA

Cancer Center Administrator

Dionne Joseph, RN Patient Navigator

Gena D. Kalil RN, BSN

Cancer Center Nurse Manager

Lance Lemoine

BRPT Lake Rehabilitation Services

Nicole Magee, CTR

Cancer Registry Director

Suzanne Neve, CTR, RHIA Cancer Registrar

Jacqueline G. O’Neill, LCSW Cancer Liaison

Salli Phillips, LCSW, OSW-C Social Services Director

Lynda Suhrer-Roussel, PhD Quality

Amy Stuckey, MBA

American Cancer Society

Jill Tomkins, RN Clinical Research

Brenda Truxillo, RN, LRT

Vice President, Radiation Oncology

Prostate Cancer Study

Chairman’s Letter

On behalf of the Cancer Committee of Our Lady of the Lake and Mary Bird Perkins, I am pleased to present the 2010 Cancer Annual Report. On the pages that follow, you will read about recent accomplishments of the Cancer Program, as well as information from a study on prostate cancer, the disease site chosen to be featured in this year’s report.

During 2009, the Cancer Program accomplished many clinical, programmatic, quality improvement and community outreach goals as part of our work with the National Cancer Institute’s Community Cancer Centers Program (NCCCP). Our NCCCP initiatives were expanded when we applied for and received an American Recovery and Reinvestment Act (ARRA) grant, allowing us to focus even more on addressing disparities in cancer care. The ARRA funding also created the opportunity for 14 additional cancer programs around the country to join NCCCP, bringing the total participants to 30.

Because cancer affects every aspect of a patient’s life, our Cancer Program’s primary focus this past year was to establish and provide patients with the most comprehensive and integrated approach to cancer care, meeting each patient’s need for quality clinical treatment and emotional and social support. We have made strides in accomplishing this goal through our patient navigation program and multidisciplinary cancer care teams.

The patient navigator serves as a consistent guide to coordinate each patient’s care, provides educational materials, answers questions and follows up after surgery—at no cost to the patient. Our patient navigator ensures patients and their families have all the information they need to make the most informed and timely decisions about their treatment plans.

Our three multidisciplinary teams are each designed and staffed specifically to ensure that patients and their families receive the most accurate cancer diagnosis and treatment available. Each team— colorectal, neuro and head-and-neck—consists of cancer specialists who are focused on each patient’s particular cancer and who have devoted their careers to fighting the very cancer with which each patient is confronted.

Another highlight in 2009 was when Mitchell Berger, MD, took the reins as medical director for the Cancer Program. Dr. Berger came to us from the Winship Cancer Institute at Grady Health Systems in Atlanta, where he served as both faculty and as the chief for the Department of Hematology and Oncology at Emory University School of Medicine. We are fortunate to have Dr. Berger with us as he leads our Cancer Program to further levels of success.

All of us at the Cancer Program appreciate the support we receive from physicians, patients and our community. We look forward to another year as we continue fighting cancer together.

Sincerely,

David S. Hanson, MD, FACP

2010 CANCER ANNUAL REPORT

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Cancer Liaison Physician’s Report

The Cancer Liaison Physician (CLP) Program was established in 1963 by the Commission on Cancer (CoC) of the American College of Surgeons (ACoS). 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. CLPs 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.

The CoC has defined five priority areas for CLP activity and recommends yearly implementation of at least one objective or activity from any of the five areas that results in a positive change within the Cancer Program. These areas include: advocacy, quality improvement, ACS partnership, clinical trials and comprehensive cancer control.

During the course of my fourth year as CLP, I feel we have strengthened our relationship with ACS by having their representatives attend each of the Cancer Committee quarterly meetings to report upcoming ACS activities and initiatives. This communication has resulted in a more informative and engaging exchange of important information and an improved overall relationship between the ACS and the Cancer Program.

In the area of quality improvement, I have been closely involved in the initial steps of developing an electronic interface between the state, regional and local cancer registries and an anticipated new anatomic pathology computer system currently being created for the Pathology Group of Louisiana (PGL), one of the largest providers of pathology services and cancer registry information in the region. The new interface should expedite the process of making vital information available to the various tumor registries, as well as improve the quality of the information delivered.

To better understand my role and responsibilities as CLP, I have participated in a number of CoCsponsored web conferences, including Making Peace with the NCDB Call for Data, The Importance of CAP Protocols and Understanding Synoptic Reporting, Implementation of The AJCC Cancer Staging Manual, Seventh Edition Revised Staging System for Breast Cancer and The Staging of Colorectal Cancer: What’s New in the Seventh Edition.

Another CLP responsibility is attendance at Cancer Committee quarterly meetings. There, I report on quality assurance studies I personally perform regarding the use of the College of American Pathologists (CAP) checklists on all pathology reports with a cancer diagnosis. Efforts continue to use these checklists to standardize pathology reports and cancer diagnoses across different institutions within the community to ensure completeness and accuracy.

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

Sincerely,

Brian W. Webb, MD

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

CANCER PROGRAM OF OUR LADY OF THE LAKE AND MARY BIRD PERKINS

Tomorrow’s Cancer Care — Right Here, Right Now.

Cancer program staff and volunteers canvassed neighborhoods to promote prostate cancer screenings.

NCCCP — Year Three The third year of the National Cancer Institute’s Community Cancer Centers Program (NCCCP) ended in June 2010.

The 14 competitively chosen sites, which included The Cancer Program of Our Lady of the Lake and Mary Bird Perkins, continued advancing the NCCCP priorities of: • improving quality of care in local community cancer programs • expanding survivorship and palliative care programs • reducing health disparities, enhancing outreach in the areas of cancer education, prevention, screening and clinical trials • participating in research that focuses on genes and biomarkers in cancer tissues • continuing implementation, enhancement and integration of electronic health records.

ARRA Funds Advance NCI Initiatives NCI is using $80 million from the American Recovery and Reinvestment Act (ARRA) to expand research benefitting patients at the 14 NCCCP pilot sites.

ARRA funding increased the number of NCCCP sites, resulting in a total of 30 cancer centers in 22 states across the nation that are developing programs to enhance community-based cancer care and creating a community cancer center network to support cancer research.

Two million dollars from ARRA will fund 14 more projects for our local cancer program over the next two years, focusing on making cancer prevention and care available to minority and uninsured populations.

Looking Forward The pilot phase of the NCCCP was a period of foundation building—assessing what was possible in bringing a diverse network of community cancer centers together to achieve common research goals and standardize work procedures and data collection practices so that progress could be measured uniformly.

The Cancer Program of Our Lady of the Lake and Mary Bird Perkins is sharing our experiences and lessons learned with new sites and the broader research community throughout the United States.

2010 CANCER ANNUAL REPORT

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Key Accomplishments by Focus Area Reduce Cancer Healthcare Disparities Our patient navigators continue to bridge the gap for many minorities and the uninsured, when an abnormal cancer screening result occurs. From the time patient navigators become aware of a patient’s abnormal finding, they guide the patient through every step of the diagnosis process, whether it’s scheduling appointments, addressing financial challenges or identifying a physician.

Our patient navigators’ primary goal is to remove any obstacle that could prevent patients from receiving the immediate care they require.

In addition to English, screening and clinical trials information is now translated into Spanish and Vietnamese to ensure clear communication within these populations.

Our Cancer Program data show that 58% of all patients screened in 2009 were minorities with 46% African American, 4% Asian American and 7.5% Hispanic Americans. Also, 8% of those screened were over age 65, and 25% of all patients screened had never been assessed before.

Improve Quality of Cancer Care Multidisciplinary care teams for colorectal, head-and-neck and neurological cancers have been created.

These teams provide enhanced physician collaboration, delivering the most seamless, comprehensive care possible for patients.

As we continue to identify genetic links to more cancers, we have enhanced our genetic counseling and testing program to provide important information to patients and their families about their risk of cancer. A board-certified geneticist is a member of our multidisciplinary teams.

Enhance Survivorship and Palliative Care Programs We have developed a breast cancer patient treatment summary and survivorship care plan to provide patients and their primary care physicians with important records of the treatment they received, including a

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

Dwayne Superneau, MD, a geneticist and member of our multidisciplinary teams, counsels a patient. detailed post-treatment follow-up plan created by best practice experiences.

Support Cancer Clinical Trials Our Cancer Program is expanding its clinical trials research infrastructure to increase the number of patients referred for clinical trials; participation by minority and underserved populations; and, the types of trials that are available to patients.

We enrolled over 200 patients in clinical trials last year with over 30% of those patients representing minorities and the underserved.

Standardize Biospecimen Collection for Research Through a Standards-Based Approach The Cancer Program continues to partner with the H. Lee Moffitt Cancer Center & Research Institute to perform state-of-the art cancer research called Total Cancer Care (TCC). By combining research efforts, we are creating a new frontier in cancer research that will potentially offer personalized cancer treatment to all patients. We have enrolled over 600 patients to date in TCC. We continue to work with our TCC clinical partners at the LSU MinorityBased Community Clinical Oncology Program, Wake Forest University and Vanderbilt-Ingram Cancer Center.

The Cancer Program and Moffitt Cancer Center have developed clinical trial workgroups to identify the trials best suited to our patients with gastrointestinal cancers and head-and-neck cancers.

Enhance Information Technology Capabilities by Converting Paper-Based Patient Records to Electronic Health Records Cohesive and comprehensive cancer care is only possible through the use of electronic medical records. During this past year, our Cancer Program has reached new levels in developing secure information technology systems for sharing patient health records with other providers.

The Cancer Program’s Community Outreach

Cancer Program staff and volunteers at the fourth annual Minority Cancer Awareness event.

CARE Network Screens Thousands for Cancer The CARE Network, funded largely through the generosity of the community and grants, helps reduce the incidence and mortality of cancer in Southeast Louisiana and improve the quality of life for those impacted by cancer. The CARE Network is a component of the Cancer Program of Our Lady of the Lake and Mary Bird Perkins and is a best practice model for a partnership-based effort to effectively fight cancer within the community.

Number of

Breast

Colorectal* Prostate

Skin

Total

Screening Events

59

75

16

15

165

People Screened

2,205

651

756

451

4,063

People Never Screened

584

402

248

381

1,615

Abnormal Findings

350

9

81

33

473

Diagnosed Cancers

23

2

9

5

39

Reaching Out to Minorities The Cancer Program hosted its second annual event in recognition of National Minority Cancer Awareness to promote the importance of early detection of cancer among racial/ ethnic minority groups. This year’s event resulted in 391 cancer screenings in one day for colorectal, skin, prostate and breast cancers and 185 blood pressure and glucose screenings.

Number of

Breast

Colorectal* Prostate

Skin

Total

People Screened

48

134

93

116

391

People Never Screened

13

88

39

103

243

Abnormal Findings

13

1

9

4

27

Diagnosed Cancers

2

1

1

0

4

A patient navigator provides follow up to all screening participants who have an abnormal finding to ensure they have access to diagnostic services. The Cancer Program continues to increase public awareness of prevention and early detection by providing free cancer screenings to those most in need. * Colorectal screening is unique in that it is a take-home kit and the return rate is dependent upon patient compliance. The CARE Network event yielded 218 kits returned, or a 33% return rate. The Minority Cancer event yielded 52 kits returned, or a 39% return rate.

2010 CANCER ANNUAL REPORT

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Cancer Related Services

Treatment

Medical Oncology

Chemotherapy Hormonal/Antihormonal Therapy Immunotherapy Infusion Therapy Peripheral Stem Cell Transplantation

OLOL • • • • •

Radiation Oncology

Radiation Therapy

External Beam Radiotherapy

High Dose Rate Brachytherapy (HDR)

Image Guided Radiation Therapy (IGRT)

Intensity Modulated Radiation Therapy (IMRT)

Prostate Seed Implants •

Stereotactic Radiosurgery

Treatment Planning

Computerized Axial Tomography (CT) •

Image Fusion (CT, MRI, PET) •

Medical Physics/Dosimetry

Positron Emission Tomography (PET) •

Virtual Simulation

Dental Oncology

•

Surgical Oncology

•

Support Services

MBP

CancerFit Enterostomal Therapy Nutritional Support Occupational, Physical and Speech Therapies Pastoral Care Respiratory Therapy Social Services

• • • • • • •

• • • • • • • • • • •

•

•

Other Services

Lymphedema Prevention Clinics Pain Management • Patient Transportation

• • •

Education

Professional Education

Allied Health Cancer Grand Rounds Continuing Education (CE) • Continuing Medical Education (CME) • Graduate Medical Education (GME) • Medical Library •

Community Education

Cancer Resource Call Center Cancer Screenings Community Library Community Outreach Elderly Services Speakers Bureau

Case Management

Tumor Conferences

Research

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• • • • •

• • • • • •

• • • • •

•

•

Clinical Research

•

•

Tumor Registry

•

•

OUR LADY OF THE LAKE | MARY BIRD PERKINS

Tumor Conferences

Multidisciplinary treatment planning conferences are held weekly to improve the care of patients with cancer. The conferences provide discussion of cancer cases and current methods of staging, diagnosis and treatment options. Our multidisciplinary team consists of surgeons, medical oncologists, radiation oncologists, pathologists and radiologists. Nurse navigators, oncology nurses, clinical research nurses, community outreach staff, cancer registrars, cancer program administrators and social service representatives also attend the conference.

In addition to the weekly general tumor conferences, OLOL’s Head & Neck Center, in conjunction with the LSU Otolaryngology Department, holds a weekly multidisciplinary tumor conference with focus on diseases of the head and neck.

In April 2009, the Colorectal Multidisciplinary Care Team began monthly tumor conferences held on the fourth Wednesday of every month. Colorectal surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, primary care physicians and gastroenterologists attend the colorectal conference.

On September 30, 2009, Frederick Greene, MD, presented Cancer Staging—2009 and Beyond to provide an overview of the new guidelines for TNM (tumor, nodes, metastasis) staging and prognostic indicators. This presentation was offered to all medical staff and allied health disciplines.

During 2009, approximately 300 cases were presented at the standard weekly tumor conferences. The cases reviewed included neoplasms of the following types and sites: Head and Neck........................................ 120 Colorectal.................................................42 All Other Sites......................................... 138

All physicians involved in the care of cancer patients are encouraged to attend and participate in these conferences.

To schedule cases for presentation, physicians should contact Tumor Conference Coordinator Dianne Griffin at (225) 215-1238.

2010 CANCER ANNUAL REPORT

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AN OVERVIEW |

Prostate Cancer

Diagnosis The only way to definitively diagnose prostate cancer is through a biopsy.

Most national health organizations recommend doctors discuss the potential benefits and drawbacks of early prostate cancer detection with men who have an average risk for developing prostate cancer and at least a 10-year life expectancy. Any man who is at high risk for prostate cancer—African Americans or individuals with a father, brother or son with prostate cancer—should have this discussion at age 45. If the patient wishes to be tested for the disease, two primary exams should be performed, including annual digital rectal exams and prostate specific antigen (PSA) testing.

During a digital rectal exam, the doctor inserts a lubricated, gloved finger into the rectum. The posterior side of the prostate can be palpated through the rectal wall. Abnormal findings include asymmetry, firm knots, lumps or swelling. Unfortunately, not all prostate gland tumors can be palpated. Some may be too small; others may be located in inaccessible areas. Therefore, a PSA test is usually also performed.

The PSA blood test measures the level of a particular protein, which is almost exclusively made by the cells within the prostate gland. When PSA first began to be used in the late 1980s, the normal range was defined as between 0 – 4 ng/ ml. However, a lab value in or out of this range does not definitely indicate whether a patient has prostate cancer. Therefore, many experts adjust the normal range based on the patient’s age. Also, many urologists don’t use just a single, one-time PSA to determine the need for further testing. Instead, they evaluate the trend of several, serial PSAs over time to decide the necessity of a prostate biopsy. Even if the patient has an elevated or abnormal PSA, there can be many other explanations such as prostate infections, medications, recent catheterizations, recent sexual intercourse, etc.

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OUR LADY OF THE LAKE | MARY BIRD PERKINS

Currently, other screening tests are being developed for prostate cancer.

Many rely on other antigens or proteins as biomarkers to help detect early prostate cancers.

If either the digital rectal exam or PSA is abnormal, then a prostate biopsy is recommended. During this procedure, the doctor or an assistant places a probe into the distal rectum. An ultrasound transducer, at the end of the probe, is used to image the prostate gland, measure the size of the prostate and identify any suspicious areas within the gland. The urologist then uses a springloaded device to rapidly obtain tissue samples from within the prostate gland.

Many urologists inject a local anesthetic through the ultrasound probe into the periprostatic tissue prior to the biopsy to help reduce the discomfort of this office procedure. Antibiotics are generally prescribed to prevent post-biopsy infections. Afterwards, the tissue sample is sent to a pathologist, who evaluates the specimen, and helps render a stage of cancer.

Treatment Options Once the diagnosis of prostate cancer has been made, the pathologist describes the cancer based on the microscopic evaluation of the positive cells and glands. The patients are given a Gleason score to describe the cancer’s aggressiveness or the rapidity at which cancer cells appear to be multiplying.

The Gleason score is usually given as a combination of two numbers, with the sum totaling between two and 10. The higher numbers denote more aggressive appearing cells and the lower numbers reflect the presence of less aggressive spread. This scoring system helps predict the behavior of the cancer and probable course of the illness.

Bone scan, Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) reveal metastasis to the bone, lymph nodes, liver or tissue surrounding

the prostate. Using information from the tests and the overall health status of the patient, doctors develop individualized treatment options.

Deciding on the Best Treatment Option There is not one treatment option that is right for all patients. The factors that influence treatment choice include both tumor factors and patient factors. The primary tumor factors are the extent of the cancer’s spread, the volume of cancer and the expected biologic behavior of the cancer: Is it likely to grow fast and spread fast or grow slowly and spread slowly?

Patient factors include age, medical condition, size of the prostate gland, urinary tract symptoms, as well as the patient’s desires and priorities. Patients are encouraged to educate themselves.

Almost always however, there are questions that are best answered by urologic surgeons, radiation oncologists and medical oncologists and other specialists who treat prostate cancer on a regular basis.

To begin the process of finding the best personal choice for treatment of prostate cancer, patients should be aware of their risk group. One of the best guides is the National Comprehensive Cancer Network’s website (www.nccn.org), which recognizes six risk groups: very low, low, intermediate, high, very high and metastatic. Once the risk group is established, the corresponding recommended management varies from active surveillance or treatment with a single modality for curative purposes to a combination of modalities for curative purposes and palliative treatment without aim to cure.

If a clinical trial is available for certain patients with specific characteristics, it should be considered. Most trials employ at least the most current standard treatment, are monitored by an expert, third party and add to the scientific information base for future patients.

As always, any treatment involves balancing the effectiveness of a regimen with the potential side effects. The expected risk of side effects and complications for each patient need to be honestly appraised by physicians aware of individual patient factors. The prostate cancer patient usually has time to weigh the options and consider what is in his best interest. He should be comfortable with that decision, realizing that any treatment or even nontreatment comes with certain risks.

Due to the high frequency of the prostate cancer diagnosis and the many excellent scientific studies regarding its treatment, there is significant information on expected outcomes from prostate cancer treatment. These prostate cancer outcome prediction tables or formulas take specific patient information such as stage, PSA, Gleason score and digital rectal examination findings and predict and compare expected outcomes. Of course, these tables and formulas or nomograms can only calculate the likelihood of a certain outcome—not the specific outcome of any one individual patient. The website www.mskcc.org utilizes the Kattan nomograms.

Ideally, patients should invest a month in the decision making process, which should allow enough time for adequate information gathering. It’s important for patients to be comfortable with both their treatment decision and the decision of their doctors. If side effects do occur, doctor and patient will need to work through those issues together.

Some of the most frequently recommended options include active surveillance; surgical removal of the prostate and, possibly, surrounding lymph nodes; radiation treatment to the prostate including external beam or implanted pellets; cryosurgery (localized freezing of the prostate gland); hormonal therapy; chemotherapy; or a combination of the above.

Surveillance and Surgery Because of the concern for overtreatment of the most favorable cancers, experts commonly recommend watchful observation of the cancer with digital rectal examination, PSAs and periodic biopsies, rather than immediate treatment. Ideal candidates for active surveillance or watchful waiting are those with small, asymptomatic, slow growing, low-grade cancers. Patients unable to tolerate more aggressive treatment options, or whose life expectancy is less than 10 years, should also consider active surveillance. For example, the protocol is sometimes recommended for men age 80 and above, who are more likely to die from another condition before the prostate cancer becomes dangerous or troublesome. Periodic PSA rechecks and repeat biopsies should be offered to patients who pursue active surveillance.

dissect the tissue and remove the prostate and lymph nodes. This procedure reduces blood loss and allows quicker recovery. In any of these surgeries, the patient is usually hospitalized for one to three days, wears a catheter from one to three weeks and recovers fully in six to eight weeks.

While watchful waiting has value for a particular subset of patients, many men prefer surgical treatment. While radical prostatectomy remains the gold standard, it has recently been modified to reduce possible side effects and complications and provide better outcomes. Performed through an incision in the lower abdomen, the procedure entails the removal of the entire prostate gland, surrounding glands and lymph nodes, which are all sent to a pathologist for microscopic analysis. The lower bladder is then reconnected to the urethral stump to maintain continuity of the lower urinary system. Some urologists prefer to perform this surgery through a perineal approach, incising the skin between the scrotum and anus to gain access to the prostate.

Radiation Therapy There are two basics methods of treating prostate cancer with radiation. External irradiation generally involves focusing a linear accelerator beam upon the prostate and, possibly, some surrounding tissue. The second type of radiation is brachytherapy. With this method, radiation sources are either implanted in the prostate permanently or a radiation source is placed temporarily within the prostate and later removed.

Recently, OLOL aquired a daVinci® robot system for surgeries including prostatectomy. This approach involves laparoscopy or robot-assisted laparoscopic surgery. daVinci® uses small incisions and trocars placed into the abdomen to gain access to the prostate.

Then, small instruments are used to

The three most significant complications, or side effects, specific to surgical removal of the prostate include urethral scarring at the site of the connection between the bladder and urethra (anastomosis), urinary incontinence and/or erectile dysfunction. The benefits of potentially removing the entire cancer with this type of surgical treatment— along with a good chance of cure and/or overall improved survival—has made radical prostatectomy a leading treatment for patients with prostate cancer in our service area.

Both external radiation and brachytherapy have been used to treat prostate cancer since the mid-20th century. External radiation technology has continued to progress with the aims of delivering radiation doses more precisely to the target and reducing the dose to normal tissues. This has enabled physicians to give higher doses to the prostate with fewer side effects and complications to the normal tissues.

The current era of radiation technology (IMRT/IGRT) for prostate cancer involves a highly integrated system of: (1) acquiring accurate images of the prostate and surrounding tissues with a 2010 CANCER ANNUAL REPORT

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AN OVERVIEW |

Prostate Cancer

CT scan, (2) transferring these images to a treatment planning computer, (3) utilizing sophisticated treatment planning software to plan the most ideal regimen of irradiation to give a higher dose to the prostate gland and significantly reduced dose to the surrounding normal tissues, (4) transferring these complex sets of treatment data to the linear accelerator, (5) translating via linear accelerator the specific personalized plan of treatment to treat the patient, and (6) assuring highly trained personnel control the delivery of the radiation. Each step of this process—including the personalized treatment data—is supervised by a strong, quality assurance program headed by the Clinical Physics Department.

Intensity-modulated radiation therapy (IMRT) is a technology that began prevalent in clinical use in the 1990s and has been available at Mary Bird Perkins Cancer Center since 2001. Since its early implementation, IMRT has proven extremely useful in the treatment of prostate cancer.

To deliver the most precise treatments, it is important to know the exact position of the prostate within the pelvis as the prostate can move slightly in respect to surrounding organs and bony structures on a daily basis. Within the last decade, image guided radiation therapy (IGRT) has been developed using several different technologies. The prostate is imaged and may be realigned prior to treatment using implanted gold markers in the prostate, Computed Axial Tomography and the newest technology—Cone-beam Computed Tomography.

Generally, external radiation with IMRT is performed on a five-day-per-week basis for a total of seven- to eight-and-ahalf weeks. Current studies are evaluating the possibility of increasing the amount of radiation per day and decreasing the total number of treatments. Results of this research are incomplete, and it is our contention that

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changing the recommended doses and number of fractions before a more complete evaluation is accomplished would be unwise.

Brachytherapy methods of treating prostate cancer utilize implanting radioactive materials into the prostate.

Most often these techniques use permanently implanted radiation sources of iodine or palladium. Guided by ultrasound imaging through the rectum, these sources are placed under general anesthesia.

Another method of brachytherapy employs catheters implanted under anesthesia. The catheter method of radiation (also called high-dose rate, or HDR) introduces a highly radioactive source inserted into a catheter for several minutes over a two-day period.

MBP has elected not to utilize HDR due to the higher convenience and excellent outcomes with the permanent implants or seeds.

Not every prostate cancer patient is a good candidate for brachytherapy. The disadvantages of brachytherapy over external radiation commonly include more severe short-term urinary side effects. Technological advancements have also improved our dose distribution with brachytherapy including better ultrasound imaging, more sophisticated software programs for planning treatment and enhanced instrumentation.

Cryosurgery, Chemotherapy and Hormonal Therapy Cryosurgery, also known as cryotherapy or cryoablation, eliminates cancer cells by freezing them. While the patient is under anesthesia, the physician places several special needles into the prostate gland with ultrasound guidance. The ends of the needles are super-cooled with argon gas. As they swell and shrink during repeated cycles of freezing and thawing, the cancer cells die. Impotence is highly probable with this type treatment. Rectal fistulas, once seen quite regularly in early studies with cryotherapy, have

OUR LADY OF THE LAKE | MARY BIRD PERKINS

become much less common.

Nonetheless, few medical centers and physicians currently offer cryosurgery.

Hormonal therapy or androgendeprivation therapy may be considered for patients who have developed metastatic prostate cancer and for those who wish to have therapy but cannot undergo surgery or radiation treatment.

Hormone therapy is often prescribed as an adjuvant for patients with rising PSA values after initial treatment with surgery or radiation. Additionally, it has the ability to boost radiation’s effectiveness or shrink the size of the gland prior to radiation. Nonetheless, the therapy alone can’t cure prostate cancer.

However, whether administered through injection or pills, it does have the ability to reduce the levels of testosterone and delay the progression of prostate cancer.

Significant side effects of these types of treatment include some cardiovascular issues, impotence, hot flashes as well as decreased libido, bone density and muscle mass.

Chemotherapy is rarely used to combat newly diagnosed, early prostate cancer.

The treatment is usually reserved for men with advanced prostate cancer or those who are no longer responding to hormonal therapy. Chemotherapeutic agents used to treat this hormonerefractory prostate cancer can be given orally or intravenously, as a single drug or in combination with several drugs.

Other Treatment Options Improving treatment options for advanced prostate cancer—including a vaccine that targets the immune system—is the subject of ongoing research. When treating their prostate cancer patients, many physicians and researchers are combining several of these treatment options. The PSA test has proven to be effective in monitoring a patient’s response to specific regimen.

If the cancer progresses, then the corresponding rise in PSA may prompt the patient’s medical team to consider other treatment options.

Figure 1 Age at Diagnosis and Comparison With National Statistics Age is the strongest risk factor for prostate cancer. OLOL/MBP data reflect greater than 95% of cases being diagnosed after the age of 50. This trend parallels the NCDB data of 97%.

Age

Percentage Percentage

0 - 19

0.0%

0.0%

20 - 29

0.0%

0.0%

30 - 39

0.1%

0.0%

40 - 49

4.6%

2.3%

50 - 59

25.8%

18.6%

60 - 69

43.8%

36.8%

70 - 79

22.0%

32.5%

80 - 89

3.7%

9.0%

0.2%

0.9%

90+

OLOL/MBP 2000 - 2009 NCDB 2000 - 2007

Mean 63 Median 64

Figure 2 Race and Comparison With National Statistics Our local data show a greater percentage of prostate cancer in our African-American population. This data reflects the make-up of our local hospital and community population.

Race

Percentage Percentage

Caucasian

70.1%

84.7%

African American

29.0%

9.6%

Other

0.9%

5.7%

Total

100%

100%

OLOL/MBP 2000 - 2009 NCDB 2000 - 2007

2010 CANCER ANNUAL REPORT

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AN OVERVIEW |

Prostate Cancer

Figure 3 Histopathologic Patterns and Comparison With National Statistics The vast majority of prostate cancers (99.6%) are adenocarcinomas. These adenocarcinomas exhibit several well-recognized histopathologic patterns, which were recognized and defined by Gleason score. This scoring system plays an important role in risk assessment and thus therapy and prognosis.

Histology

Percentage Percentage

Adenocarcinoma

99.6%

95.9%

Other Specified Types

0.4%

4.1%

OLOL/MBP 2000 - 2009 NCDB 2000 - 2007

Figure 4 TNM/CS Mixed Stage at Diagnosis and Comparison With National Statistics OLOL/MBP data by stage of disease closely parallels the national statistics except for a smaller number of unstaged tumors.

AJCC TNM/CS Mixed Stage

Percentage Percentage

Stage 0

0.0%

0.0%

Stage I

3.4%

2.1%

Stage II

77.7%

78.3%

Stage III

12.5%

7.5%

Stage IV

3.8%

5.2%

Unknown

2.6%

6.9%

OLOL/MBP 2000 - 2009 NCDB 2000 - 2007

Figure 5 Treatment Modalities: Entire First Course and Comparison With National Statistics The largest percentage of Cancer Program patients received surgery only as a first course treatment, which is considered the leading treatment for prostate cancer patients.

Treatment Type

12

Percentage Percentage

Surgery Only

72.5%

40.0%

Radiation Only

14.8%

19.8%

Radiation & Hormone Therapy

4.5%

18.4%

Hormone Therapy Only

0.6%

4.5%

No Treatment

1.4%

11.9%

Other Specified Therapy

6.4%

5.4%

OUR LADY OF THE LAKE | MARY BIRD PERKINS

OLOL/MBP 2000 - 2009 NCDB 2000 - 2007

Figure 6 Observed Five-Year Prostate Cancer Survival Rates by Stage and Comparison With National Statistics The five-year survival rate among our prostate cancer patient population has been compared with the most recent national data available. Our local data reflect an overall survival rate that closely parallels NCDB, with a slight increase in survival seen in OLOL/MBP Stage IV cases.

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

0

I

II

III

IV

Overall

OLOL/MBP 2000 - 2004 NCDB 1998 - 2002

Data from 1,406 Programs (National)

2010 CANCER ANNUAL REPORT

13

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

OLOL Cancer Registry reference date is 1987, and it contains data on 27,745 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. High importance is placed on data quality using these guidelines, and physician members of the Cancer Committee review a sample of the cases for quality assurance. Once part of the registry database, these cases are followed for the life of the patient.

During 2009, there were 1,321 new cancer cases entered into the OLOL registry database. Of these, 1,288 were analytic cases (newly diagnosed and/or received all or part of their first course treatment at this facility). The top five sites were lung, colon, prostate, kidney/renal pelvis and bladder.

OLOL Top Five Analytic Sites N/672

Lung................................................... N/224 Colon...................................................N/142 Prostate.............................................. N/126 Kidney.................................................. N/96 Bladder.................................................N/84

The MBP Cancer Registry reference date is 1989, and it contains data on 13,021 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. 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 for the life of the patient.

During 2009, there were 942 new cancer cases entered into the MBP registry database. Of these, 801 were analytic cases (newly diagnosed and/or received all or part of their first course treatment at this facility). The top five sites were breast, prostate, lung, rectum/rectosigmoid and larynx.

MBP–Baton Rouge Top Five Analytic Sites N/589

Breast................................................. N/222 Prostate...............................................N/156 Lung....................................................N/152 Rectum................................................. N/35 Larynx................................................... N/24

The registries maintain cancer data that are available for use by clinical and administrative staff at OLOL and MBP. All information collected is kept completely confidential. During 2009, the registries received requests for statistical reports including analytic studies, annual statistics, research activities, quality management studies, healthcare delivery, reporting to National Cancer Data Base (NCDB) and participation in the Facility Information Profile System (FIPS) on the American Cancer Society’s website. This year OLOL/MBP was chosen to participate in the beta-testing phase of the Rapid Quality Reporting System (RQRS). Sponsored by the Commission of Cancer, this program is scheduled to become available to other CoC approved facilities by the end of 2010.

Data is submitted to the Louisiana Tumor Registry in compliance with state reporting requirements to support statewide improvements in cancer detection and treatment. The registry also participates in the NCDB Cancer Program Practice Profile activities.

OLOL & MBP Data Submission

14

OUR LADY OF THE LAKE | MARY BIRD PERKINS

Louisiana Tumor Registry (LTR) National Cancer Data Base (NCDB) Facility Information Profile System (FIPS) Rapid Quality Reporting System (RQRS)

OLOL 2009 Site Distribution Table

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

Total Cases 1,321 41 26 15 3 45 55 295 5 2 145 8 5 16 39 61 3 11 42 4 38 8 2 2 3 1 53 10 43 138 3 129 6 96 51 44 3 1 2 3 6 9 4 10 4 2 264 28 193 38 4 1 44 41 3 11 35 192 87 98 6 1

Class A N/A 1,288 41 26 15 3 44 50 291 5 2 142 8 5 16 39 60 3 11 42 4 38 6 2 1 3 0 52 10 42 135 3 126 6 95 51 41 3 1 1 3 6 9 4 10 3 1 256 27 187 37 4 1 44 41 3 11 35 186 84 96 6 0

33 0 0 0 0 1 5 4 0 0 3 0 0 0 0 1 0 0 0 0 0 2 0 1 0 1 1 0 1 3 0 3 0 1 0 3 0 0 1 0 0 0 0 0 1 1 8 1 6 1 0 0 0 0 0 0 0 6 3 2 0 1

M 790 22 14 8 1 22 3 161 2 0 75 7 5 11 19 35 2 5 8 2 6 0 0 0 0 0 35 7 28 138 3 129 6 45 23 24 0 1 2 2 3 3 0 8 3 2 151 21 111 14 4 1 33 31 2 6 21 142 69 68 4 1

Sex

F

0

I

Stage II

III

IV

Not App

Unknown

531 19 12 7 2 23 52 134 3 2 70 1 0 5 20 26 1 6 34 2 32 8 2 2 3 1 18 3 15 0 0 0 0 51 28 20 3 0 0 1 3 6 4 2 1 0 113 7 82 24 0 0 11 10 1 5 14 50 18 30 2 0

62 0 0 0 0 0 3 5 1 0 1 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 1 0 0 1 0 0 6 3 3 0 0 0 2 2 0 0 0 44 41 1 2 0

299 0 0 0 0 0 18 72 0 0 45 1 2 3 1 18 0 2 26 0 26 0 0 0 0 0 21 3 18 3 0 0 3 0 0 12 1 0 0 3 1 0 3 4 0 0 52 8 42 1 1 0 15 14 1 2 0 78 22 55 1 0

237 0 0 0 0 0 11 64 1 0 33 3 0 0 7 18 0 2 5 0 5 0 0 0 0 0 6 3 3 101 1 98 2 0 0 4 0 1 0 0 1 0 0 1 1 0 16 5 11 0 0 0 12 12 0 0 0 18 9 8 1 0

176 0 0 0 0 0 8 54 2 0 33 1 0 6 3 8 1 0 3 0 3 1 0 0 1 0 2 0 2 22 2 20 0 0 0 6 0 0 0 0 2 2 1 1 0 0 54 3 43 8 0 0 3 3 0 4 0 19 6 11 2 0

210 0 0 0 1 0 5 59 1 1 18 2 3 2 22 7 0 3 2 0 2 1 1 0 0 0 20 4 16 7 0 7 0 0 0 11 1 0 0 0 1 5 0 3 1 0 85 6 58 20 1 0 1 1 0 1 0 17 3 14 0 0

197 41 26 15 0 44 0 7 0 0 3 0 0 0 0 1 1 2 4 4 0 0 0 0 0 0 0 0 0 1 0 0 1 95 51 3 0 0 0 0 0 2 0 0 0 1 7 1 5 0 0 1 1 0 1 1 35 2 1 1 0 0

107 0 0 0 2 0 5 30 0 1 9 1 0 5 5 6 1 2 2 0 2 4 1 1 2 0 3 0 3 1 0 1 0 0 0 3 1 0 1 0 0 0 0 0 1 0 36 1 25 8 2 0 10 9 1 3 0 8 2 6 0 0

A: Analytic | N/A: Non-Analytic | M: Male | F: Female | Not App: Not Applicable | NOS: Not Otherwise Specified

2010 CANCER ANNUAL REPORT

15

MBP 2009 Site Distribution Table

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

Total Cases 942 13 4 9 2 23 249 79 8 2 5 14 2 5 37 6 5 4 1 1 32 11 12 1 2 3 3 27 4 23 206 199 7 12 54 5 1 4 4 4 5 1 7 14 9 194 25 140 29 7 1 2 4 4 17 17 8 9

Class A N/A 801 11 2 9 2 19 222 70 8 1 2 13 1 5 35 5 4 4 0 1 25 11 7 0 1 3 3 19 3 16 163 156 7 3 54 5 1 4 4 4 5 1 7 14 9 176 24 125 27 5 0 1 4 3 16 8 4 4

141 2 2 0 0 4 27 9 0 1 3 1 1 0 2 1 1 0 1 0 7 0 5 1 1 0 0 8 1 7 43 43 0 9 0 0 0 0 0 0 0 0 0 0 0 18 1 15 2 2 1 1 0 1 1 9 4 5

M 473 9 4 5 0 14 0 48 3 1 3 9 1 2 24 5 4 3 1 1 0 0 0 0 0 0 0 11 2 9 206 199 7 4 32 2 0 3 1 2 3 1 3 10 7 118 16 86 16 4 1 1 2 1 9 12 5 7

Sex

F

0

I

Stage II

III

IV

Not App

Unknown

469 4 0 4 2 9 249 31 5 1 2 5 1 3 13 1 1 1 0 0 32 11 12 1 2 3 3 16 2 14 0 0 0 8 22 3 1 1 3 2 2 0 4 4 2 76 9 54 13 3 0 1 2 3 8 5 3 2

53 0 0 0 0 0 49 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 2 1 0 0 0 0 0 0 0 1 1 0

150 0 0 0 0 0 81 5 0 1 0 0 0 0 3 1 0 0 0 0 7 2 4 0 0 1 0 10 1 9 7 0 7 0 5 1 0 0 0 0 0 0 3 1 0 30 7 23 0 4 0 0 4 0 0 1 1 0

253 0 0 0 0 0 58 27 2 0 1 4 0 2 17 1 0 0 0 1 4 2 0 0 0 1 1 6 2 4 144 144 0 0 4 0 0 2 0 0 0 0 0 2 0 9 4 5 0 0 0 0 0 0 0 0 0 0

125 0 0 0 0 0 21 19 5 0 0 3 0 1 9 1 0 0 0 0 9 6 1 0 1 0 1 1 0 1 6 6 0 0 11 0 0 2 3 0 1 0 1 4 0 55 0 44 11 0 0 0 0 2 0 1 1 0

127 0 0 0 0 0 8 10 1 0 1 2 0 1 4 1 0 0 0 0 4 1 1 0 0 1 1 2 0 2 3 3 0 0 28 4 1 0 1 3 1 1 1 7 9 67 7 46 14 1 0 1 0 0 0 4 1 3

56 11 2 9 1 19 0 0 0 0 0 0 0 0 0 0 4 4 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 3 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16 0 0 0

37 0 0 0 1 0 5 9 0 0 0 4 1 1 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 3 0 0 5 0 0 0 0 0 3 0 2 0 0 12 4 6 2 0 0 0 0 1 0 1 0 1

A: Analytic | N/A: Non-Analytic | M: Male | F: Female | Not App: Not Applicable | NOS: Not Otherwise Specified

16

OUR LADY OF THE LAKE | MARY BIRD PERKINS

Tomorrow’s Cancer Care— Right Here, Right Now.

As a partner of the National Cancer Institute’s (NCI) National Community Cancer Centers Program (NCCCP), we are developing a national model for community cancer centers. This means cancer patients in our own community are receiving the highest standard of care available—right here, right now.

The quality of our Cancer Program is underscored by our selection by NCI, a world leader in cancer research.

We are proud to be the only site in Louisiana, the only site in the Gulf South and one of 30 centers across the nation working with NCI to improve cancer care for patients in community settings.

www.marybird.org

www.ololrmc.com

Defeating cancer together.

5000 Hennessy Boulevard Baton Rouge, LA 70808-4398 (225) 765-8879 ololrmc.com

4950 Essen Lane Baton Rouge, LA 70809-3432 (225) 215-1515 marybird.org

ONC-269 (11/10) BRP