2014 Cancer Services
Annual Report
CANCER SERVICES
2 | 2014 Cancer Services Annual Report
Introduction
Vincent Bjorling, MD 5
Clinical Trials AT REGIONAL WEST 6
Cancer
CONFERENCE 9
Cancer REGISTRY 9
Survivorship PROGRAM 11
Palliative Care Comparison 13
OF CANCER DATA 16
Primary Site TABLE 17
Cancer Committee MEMBERSHIP 18
Regional West
GOALS & ACCOMPLISHMENTS 19
Prostate Cancer GRAPHS 20
Radiation Treatment FOR PROSTATE CANCER 22
Prostate Cancer
SURGICAL TREATMENT OPTIONS 24
Glossary OF TERMS 26
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“ AT REGIONAL WEST WE ARE
COMMITTED to involving seasoned professionals in every facet of cancer diagnosis, treatment, and follow-up care to ensure the best possible outcome for our patients.” – Vincent Bjorling, MD
4 | 2014 Cancer Services Annual Report
Introduction
I’m pleased to introduce Regional West Medical Center’s 2014 Cancer Services annual report. This year our focus is on prostate cancer. About one man in seven will be diagnosed with prostate cancer during his lifetime. Prostate cancer is the second leading cause of cancer death in American men, behind only lung cancer. Prostate cancer occurs mainly in older men. About six cases in 10 are diagnosed in men aged 65 or older, and it is rare before age 40. The average age at the time of diagnosis is about 66. About one man in 38 will die of prostate cancer. In 2012, prostate cancer was the most diagnosed cancer for men at Regional West Medical Center, with 30 cases diagnosed during the year. The cases comprised eight percent of that year’s cancer diagnoses for Regional West, compared with 13 percent of Nebraska’s total prostate cancer diagnoses for 2012.
Vincent Bjorling, MD Chairman, Cancer Committee
Providing personalized, individualized cancer care is a team effort, and in this year’s annual report we spotlight several fairly new programs at Regional West, including the Survivorship program, the Clinical Trials program, as well as a focus on Palliative Care and Urology. At Regional West, we are committed to involving seasoned professionals in every facet of cancer diagnosis, treatment, and follow-up care to ensure the best possible outcome for our patients. For more information about cancer services, support programs, and activities for cancer survivors and their loved ones, call Regional West Physicians Clinic-Oncology at 308.630.2101, the Cancer Treatment Center-Scottsbluff at 308.630.1348, or the Dorwart Cancer Care CenterSidney at 308.254.9192. Sincerely, Vince Bjorling, MD Chairman, Cancer Committee
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Clinical Trials
NOW at Regional West Medical Center In recent years, cancer clinical trials – research studies that use human volunteers to test new treatments – have led to dramatic, positive changes in preventing, diagnosing, and treating cancer. Through a Regional West Medical Center partnership with the Missouri Valley Cancer Consortium (MVCC), cancer survivors in our area now have the exciting opportunity to participate in clinical trials that previously were not offered locally.
Michele Lambert, OCN, BSN, RN Clinical Trials Coordinator
Regional West Medical Center Clinical Trials Coordinator Michele Lambert, RN, BSN, OCN, works closely with the MVCC and Regional West providers to offer clinical trials covering a number of disease sites. Establishing a clinical trials program has been a goal of Regional West’s Cancer Committee since 2012; Regional West’s clinical trials program has been in place for just over a year. According to Lambert, the number of clinical trials varies day-to-day, week-by-week. There are currently a wide variety of studies being offered, but the number of trials and those enrolled change as trials open and close throughout the year. All labs and scans are administered in Scottsbluff, as well as any medication for the trial itself. “It’s such an exciting opportunity for Regional West patients; we’re always searching for new trials,” said Lambert. “They can participate in the same trials being offered in Denver and Omaha – without the need to travel long distances.” Patients are evaluated before they can participate in a clinical trial and must meet guidelines, called eligibility criteria, that specify who can and cannot participate. To ensure the most reliable results, participants in a clinical trial must be alike in key ways. Examples of eligibility criteria for a cancer treatment trial include:
• Type of cancer
• Stage of cancer
• Age
• Gender
• Other past or current treatments
Once patients are accepted into the program, they become completely anonymous when their data is reported to the MVCC, and are identified
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“ IT’S SUCH AN EXCITING
OPPORTUNITY for Regional West patients... They can participate in the same trials being offered in Denver and Omaha – without the need to travel long distances.” – Michele Lambert, OCN, BSN, RN
solely by a number. Personalized care is the name of the game at Regional West, though, said Lambert, and patients are anything but ‘just a number.’ “Because we’re involved in a smaller number of clinical trials here than at a larger hospital, we develop a closer relationship that might not be possible elsewhere,” she explained. “With a small group of providers and health care professionals involved in the enrollment process, a bond naturally forms and our patients feel more comfortable sharing things because of the trust level we achieve.” Involvement in a clinical trial means committing to the treatment criteria outlined in the protocol for the trial, with each treatment cycle consisting of approximately 21 to 28 days. The six to 12 month commitment includes a Regional West appointment every 14 to 28 days. Every trial is different – post-trial, some people will be followed for up to 10 years; others will see the trial end much sooner. “There is absolutely no cost involved on the part of our patients to participate in a clinical study,” said Lambert. With all the advances made in cancer treatment, partially thanks to information gleaned from clinical trials, nationwide just five percent of cancer patients currently participate in the studies (Source: American Cancer Society). According to Lambert, clinical trials aid significantly in cancer research and treatment development, yet several misconceptions remain. “Some people think
Deciding to take part in a clinical trial When you need treatment for cancer, you may want to think about joining a clinical trial. Like all treatment options, clinical trials have possible benefits and risks. By looking closely at all options, including clinical trials, you are taking an active role in a decision that affects your life. This section has information you can use when making your decision.
Possible benefits
•Y ou will have access to a new treatment that is not available to people outside the trial.
• T he research team will watch you closely.
• If the treatment being studied is more effective than the standard treatment, you may be among the first to benefit.
• T he trial may help scientists learn more about cancer and help people in the future.
Possible risks
• The new treatment may not be better than, or even as good as, the standard treatment.
•N ew treatments may have side effects that doctors do not expect or that are worse than those of the standard treatment.
Deciding | Continued on page 8
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that taking part in clinical trials is a ‘last ditch effort’ in treating the cancer,” she said. “When in fact, patients are always given the standard of care on an oncology clinical trial and quite often receive additional trial specific medication that may have benefits in treating their cancer.” Patients are closely monitored throughout their care while in the study, both during and after treatment. Lambert concluded, “The clinical trial program is just a great service being provided to our community. Each day, new trials are opening up – it’s a very exciting time in cancer care.” Cancer survivors are urged to contact their physician, or Michele Lambert at 308.630.2429 with questions regarding potential study qualifications or for enrollment.
Deciding | Continued from page 7
•Y ou may be required to make more visits to the doctor than if you were receiving standard treatment. You may have extra expenses related to these extra visits, such as travel and childcare costs. •Y ou may need extra tests. Some of the tests could be uncomfortable or time consuming. •E ven if a new treatment has benefits in some patients, it may not work for you. •H ealth insurance may not cover all patient care costs in a trial.
Who can join
• Being in a certain age group.
Every clinical trial has a protocol, or study plan, that describes what will be done during the trial, how the trial will be conducted, and why each part of the trial is necessary. The protocol also includes guidelines for who can and cannot take part in the trial. These guidelines are called eligibility criteria.
• Medical history.
• Current health status.
Common eligibility criteria include:
•H aving a certain type or stage of cancer.
•H aving received (or not having received) a certain kind of therapy in the past.
Criteria such as these help reduce the medical differences among people in the trial. When people taking part in a trial are alike in key ways, researchers can be more certain that the results are due to the treatment being tested and not to other factors. Some people have health problems besides cancer that could be made worse by the treatments in a trial. If you are interested in joining a trial, you will receive medical tests to be sure that you fit for the trial.
Courtesy of The National Cancer Institute at the National Institutes of Health, www.cancer.gov.
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2014
CANCER CONFERENCE
Cancer conferences provide a forum for formalizing the disease stage of the patients discussed using nationally recognized, evidenced-based treatment guidelines, when appropriate, and providing continuing medical education. Regional West Medical Center held 22 bimonthly multidisciplinary Cancer Conferences in 2014 to review and discuss current trends in the treatment of cancer. Pathologist Peter Schilke, MD, served as the 2014 coordinator. Physician representatives from all the appropriate disciplines, as well as other cancer health care providers, attend and participate in these conferences. Average attendance for physicians who actively participated in cancer care was 11. The multidisciplinary average attendance was 10. In 2014, 249 cases were cases were presented. Sites discussed included: breast, lung, colon, corpus uteri, melanoma, esophagus, prostate, testis, rectum, ovary, kidney, brain, bladder, thyroid, lymphoma, head/neck carcinoma, stomach, pancreas, and unknown primary. To arrange for case presentation at Cancer Conference or for further information regarding the Cancer Registry, please call 308.630.2421.
Cancer Registry
The Cancer Registry is a component of the cancer program and is responsible for the accurate and timely collection of cancer patient data used for the evaluation of patient outcomes. The Cancer Registry is responsible for monitoring and coordinating many of the activities of Regional West Medical Center’s cancer program and our participation in the American College of Surgeons (ACoS) Commission on Cancer (CoC) as an accredited program.
Regional West’s Cancer Registry has been accredited since 1985.
The Cancer Registry is responsible for the data collection and followup of all cancer patients diagnosed and/or treated at Regional West. These cases are part of the computerized database utilizing Rocky Mountain Cancer Data Systems in Salt Lake City, Utah. The updated registry computer system allows instant retrieval capabilities. The database includes information on
By Cindy Keller, CTR Cancer Registry Coordinator
demographics, anatomic site, extent of disease at the time of diagnosis, history, staging of the cancer, and treatment summary. There were a total of 360 analytic cases added to the registry in 2014. See the primary site table on page 17.
In October, the data specialist and cancer registrar attended the 37th Annual Tumor Registrars Association of Nebraska (TRAN) workshop in Omaha, Neb.
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“ SURVIVORSHIP CARE IS ONGOING. This can be a challenging time and we want to ensure that each patient is provided with this essential part of his or her cancer care.” – Sue Schoeneman, AOCNP, ACNP, MSN
For more information on Survivorship Care or to make an appointment, please contact Sue Schoeneman, AOCNP, ACNP, MSN, at 308.630.2101 or Susan.Schoeneman@rwhs.org
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Survivorship PROGRAM
By Sue Schoeneman, AOCNP, ACNP, MSN Advanced Oncology Certified Nurse Practitioner As of January 2012, there were an estimated 13.7 million cancer survivors in the United States, and that number is expected to grow to approximately 18 million by 2022. As the population of cancer survivors increases, the need for comprehensive care becomes crucial. In 2005, the Institute of Medicine (IOM) and the National Research Councils (NRC) publicized From Cancer Patient to Cancer Survivor: Lost in Transition. A number of recommendations were derived from the publication. Among them, survivorship is viewed as a distinct stage of cancer care. Patients completing treatment will receive a comprehensive treatment summary and follow-up plan provided by principle providers within their oncology group managing their treatment. In 2012, the American College of Surgeons’ Commission on Cancer reinforced this need and shifted to standards that include survivorship care. At Regional West, our goal is to meet the recommendations set by the IOM and the NRC and meet standards of care set by the Commission on Cancer to provide optimal outcomes for our cancer patients as they transition into survivorship care.
Sue Schoeneman, AOCNP, ACNP, MSN Advanced Oncology Certified Nurse Practitioner
Cancer Services at Regional West Health Services provides survivorship care that meets the recommendations of cancer care. This care includes: • Surveillance for cancer recurrence and secondary cancers. • Tools for management of side effects from treatment. • Recommendations for appropriate screenings. • Assistance with healthy lifestyle management, nutritional needs, weight management, and smoking cessation. • Assistance with psychosocial needs and social work referral if needed, for issues such as workplace, home, or finances. • Suggesting available support groups. • Assistance in managing care in coordination with your oncologist and primary care provider. In addition, each patient will receive a treatment summary and follow-up care plan, which is now referred to as a survivorship care plan. A copy of the care plan will also be provided to the patient’s primary care provider. Survivorship care is ongoing. Patients and their providers will discuss an appropriate schedule for follow-up appointments. This can be a challenging time and we want to ensure that each patient is provided with this essential part of his or her cancer care.
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“ ALTHOUGH THE FOCUS OF
PALLIATIVE CARE is on improving quality of life, there is unexpected evidence that the symptom control and support provided by palliative care may actually extend sur vival time for patients with terminal illnesses.” – Connie Beehler, MD, MS, FAAHPM
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Palliative Care
By Connie Beehler, MD, MS, FAAHPM Medical Director, Palliative Care
Palliative care offers treatment of discomfort, symptoms, and suffering associated with a serious illness such as cancer, heart failure, or severe lung disease. The goal of palliative care is to improve the quality of life for individuals with serious illnesses by relieving suffering while optimizing function and maintaining mental clarity. Palliative care seeks to help patients live life to the fullest extent possible and make the most of each day, regardless of the diagnosis or prognosis. Palliative care also assists patients and families in the process of setting realistic goals, obtaining information about care options, and making decisions about treatment. Palliative medicine is a recognized medical specialty with board certification available. At Regional West Medical Center, care is provided by a physician and nurse practitioner. The word “palliative,” as described by Webster, is derived from the Latin word palliates: to cloak or conceal (as in pain).
Connie Beehler, MD, MS, FAAHPM
How is palliative care different from hospice care? Hospice is actually a type of palliative care. Both hospice and palliative care offer pain and symptom management, help relieve suffering, and attempt to address the needs of the whole person. However, hospice care is limited by government regulations to the final six months of life and was designed to care for patients who are no longer receiving aggressive or curative treatment. In contrast, palliative care is appropriate at any time during a serious illness – regardless of the diagnosis, treatment chosen, or prognosis. People do not need to have a terminal disease or be close to the end of life to receive palliative care. In fact, patients can receive palliative care at the same time as they are receiving aggressive treatments intended to cure their illness.
When is palliative care appropriate? Palliative care is appropriate whenever physical, emotional, social, or spiritual suffering limits quality of life during the course of a serious illness. It is also appropriate when a patient and/or family are struggling with difficult health care decisions or to understand the likely effects or results of a medical condition. Care can begin as early as the time of diagnosis and continue throughout the course of the illness – regardless of whether or not a cure is likely. Palliative care can help control symptoms and distress associated with treatment like chemotherapy, as well as symptoms related to the underlying disease process. Although the focus of palliative care is on improving quality of life, there is unexpected evidence that the symptom control and support provided
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by palliative care may actually extend survival time for patients with terminal illnesses. One study has shown that patients with stage IV nonsmall cell lung cancer lived longer when palliative care was involved, along with usual cancer treatments, than the patients who received the same treatment without palliative care.1
Suffering and palliative care The treatment of suffering is a major focus of the palliative care team. Physical suffering during a serious illness may include symptoms of nausea, fatigue, dyspnea, weakness, and anorexia, as well as pain. A study of patients with advanced cancer revealed the surprising fact that patients identified fatigue as the most common symptom and most distressing in terms of the negative impact on quality of life for the patients surveyed.2 Suffering can also have emotional, social, and spiritual sources. Emotional suffering can include depression, anxiety, fear, or loneliness. It may also be caused by a series of distressing disease-related losses, such as the loss of financial security, inability to work or feel productive, and the loss of independence. The inability to leave the house, get out of bed, or walk alone can also cause suffering. In addition, serious illnesses can threaten one’s sense of self or purpose in life. Examples of social suffering include loneliness, concerns about finances, worry about being a burden to one’s family, or conflicts within the family about treatment choices or goals. Spiritual distress can include guilt, questions about why this happened or why God doesn’t intervene, concerns about what happens after death, and loss of hope and meaning. Sometimes suffering is increased by one’s interpretation of the meaning of the disease or symptoms. Psychosocial or spiritual distress may amplify the suffering from physical symptoms and may need to be addressed in order to gain control of physical suffering. Serious illnesses always involve suffering for the patient and loved ones as well; this suffering is even more intense when the illness is likely to be fatal or when family feels helpless to make things better.
Palliative care and decision-making Decisions about treatment choices need to be based on accurate information about the disease, treatment options, and the likely outcomes of the illness. The individual’s values, beliefs, and goals also influence decision-making and are very important. Palliative care supports decision-making by helping patients and families identify realistic goals and then selecting approaches that can help them best achieve those goals. Honoring the ethical principle of autonomy and patients’ right to self-determination are priorities for the Palliative Care team. Palliative care can help with
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discussions about advance directives including “Do Not Attempt Resuscitation” or Physician Orders for Life Sustaining Treatment (POLST) orders that allow individuals to document their wishes for care. The Palliative Care team can also help patients and families understand what their power of attorney for health care needs to know and can suggest helpful questions to ask their physicians.
References: 1.) Jennifer S. Temel, MD; Joseph A. Greer, PhD; Alona Muzikansky, MA; Emily R. Gallagher, RN; Sonal Admane, MB, BS, MPH; Vicki Jackson, MD, MPH; Constance M. Dahlin, APN; Craig D. Blinderman, MD; Juliet Jacobsen, MD; William F. Pirl, MD, MPF; J. Andrew Billings, MD; and Thomas J. Lynch, MD. N Engl J Med 2010; 363:733-742 | August 19, 2010 | DOI: 10.1056/ NEJMoa1000678. 2.) K utner JS1, Bryant LL, Beaty BL, Fairclough DL. Time course and characteristics of symptom distress and quality of life at the end of life. J Pain Symptom Manage. 2007 Sep;34(3):227-36.
Fast facts about palliative care
•P alliative care seeks to improve quality of life during a serious illness.
•P alliative care treats people with serious illnesses such as cancer, COPD, or CHF.
•P alliative care treats diseaserelated symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite, and difficulty sleeping.
•E motional, spiritual, and social distress are also common in serious illnesses. • I n a study of patients with stage IV lung cancer, palliative care improved quality of life and the patients lived longer than those receiving usual treatment. •P alliative care may give you more control over your care by helping you understand your disease, the choices available to you, and the questions to ask your doctor.
What can palliative care offer you and your family?
•M edical help in controlling discomfort and symptoms.
• I nformation to help you make appropriate health care decisions.
•G uidance with difficult and complex treatment choices.
• Support during a difficult time.
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2014 CANCER
COMPARISONS In 2014, there were 360 cases of cancer and reportable tumors in the Regional West Medical Center Cancer Registry. Of these, 35 cases were non-analytic, and a total of 395 cases qualified for analysis (see primary site table on p. 17). Breast cancer is the most frequently diagnosed and treated primary site at Regional West. The “All” graphs shown include analytic cases only.
2014 COUNTS BY COUNTY OF RESIDENCE
COMPARISON CHARTS
REGIONAL WEST
Dawes 17
18%
Breast Lung & Bronchus
49%
365 TOTAL
15%
Prostate Melanoma of Skin
8%
Garden 10
Cheyenne 27
Kimball 7
Grant 2
Hooker 1
Arthur
McPherson
Keith 5
Deuel 1
Breast
Frontier
Dundy
Hitchcock
Red Willow
17% 72
13
8%
NATIONAL Breast
Prostate Bladder Lung & Bronchus
16 12
21%
Buffalo 1
Melanoma of Skin 17 11%
156 CASES
46%
All other sites
13%
26
Colon Melanoma of Skin
2% 8%
Dawson
TOP FIVE INCIDENCE SITES-MEN
Prostate 14%
Lincoln
Hayes
Lung & Bronchus 1,422 TOTAL
Logan
Chase
Out of state: 53
21%
Thomas
Perkins
Total: 360 cases for 2014
NEBRASKA
42%
Morrill 21
Banner 3
All other sites
2% 8%
Box Butte 43
Scotts Bluff 156
Colon
Cherry 1
Sheridan 9
Sioux 3
10%
8%
Non-Hodgin’s Lymphoma Other
TOP FIVE INCIDENCE SITES-WOMEN
Lung & Bronchus 44%
117,171 TOTAL
Prostate 16%
Colon
71
35%
67
204 CASES
Melanoma of Skin 3% 8%
8%
All other sites
SOURCE: American College of Surgeons, National Cancer Data Base (NCDB), Hospital Comparison Benchmark report, 2012.
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33%
11
5%
16
8%
17
8%
Breast Lung & Bronchus Colon Corpus Ulteri
22
11%
Melanoma of Skin Other
CANCER INCIDENCE BY
PRIMARY SITE
2014 Cancer Treatment Center and Dorwart Cancer Care Center Cases
Primary Site
ALL Cases Analytic Sex Best AJCC Stage (includes Cases M F Stage 0 Stage I Stage II Stage III Stage IV Not Staged non-analytic) Buccal Cavity/Pharynx 12 11 7 4 0 2 1 3 5 0 Lip 2 1 1 0 0 0 0 0 1 0 Tongue 3 3 2 1 0 0 0 1 2 0 Major Salivary Gland 1 1 0 1 0 0 1 0 0 0 Gum/Other Mouth 3 3 1 2 0 2 0 1 0 0 Tonsil 3 3 3 0 0 0 0 1 2 0 Digestive System 59 57 27 30 0 7 8 19 17 6 Esophagus 7 7 4 3 0 2 1 4 0 0 Stomach 2 2 1 1 0 0 1 1 0 0 Small Intestine 1 1 1 0 0 0 0 0 1 0 Colon, Excluding Rectum 24 24 7 17 0 4 3 9 7 1 Rectum & Rectosigmoid 8 8 6 2 0 1 2 2 2 1 Anus/Anal Canal 2 2 1 1 0 0 0 1 1 0 Liver 3 3 3 0 0 0 0 1 1 1 Gallbladder 2 1 0 1 0 0 1 0 0 0 Other Biliary 1 1 1 0 0 0 0 1 0 0 Pancreas 6 5 2 3 0 0 0 0 5 0 Other Digestive Organs 3 3 1 2 0 0 0 0 0 3 Respiratory/System 42 41 16 25 1 4 3 8 25 0 Nasal Cavity/Sinuses/Larynx 6 6 3 3 1 0 3 0 2 0 Lung, Bronchus 36 35 13 22 0 4 0 8 23 0 Bones & Joints 1 0 0 0 0 0 0 0 0 0 Soft Tissue 2 1 1 0 0 0 0 1 0 0 Skin (Exc. Basal & Sq. Ca) 31 28 17 11 12 12 2 1 1 0 Melanoma of the Skin 31 28 17 11 12 12 2 1 1 0 Breast 69 68 1 67 10 21 21 10 5 1 Female Genital 31 31 0 31 1 21 2 4 3 0 Cervix Uteri 2 2 0 2 0 1 0 1 0 0 Corpus Uteri 16 16 0 16 0 14 1 0 1 0 Uterus 3 3 0 3 0 3 0 0 0 0 Ovary 6 6 0 6 0 1 1 3 1 0 Vulva 4 4 0 4 1 2 0 0 1 0 Male Genital 53 32 32 0 0 15 11 4 2 0 Prostate 47 26 26 0 0 10 10 4 2 0 0 0 Testis 4 4 4 0 0 3 1 0 Penis 2 2 2 0 0 2 0 0 0 0 Urinary System 31 30 23 7 10 10 7 2 1 0 Urinary Bladder 21 21 16 5 10 5 6 0 0 0 Kidney & Renal Pelvis 10 9 7 2 0 5 1 2 1 0 Brain & Other Nervous Sys. 14 12 4 8 N/A N/A N/A N/A N/A 12 Endocrine System 14 13 8 5 0 2 2 1 3 5 Thyroid Gland 7 7 4 3 0 2 2 1 2 0 Other Endocrine 7 6 4 2 N/A N/A N/A N/A 1 5 Lymphatic System 20 20 14 6 0 4 6 3 7 0 Hodgkin’s Disease 3 3 2 1 0 1 1 0 1 0 Non-Hodgkin’s Disease 17 17 12 5 0 3 5 3 6 0 Multiple Myeloma 5 5 2 3 N/A N/A N/A N/A N/A 5 Blood/Leukemia 6 6 2 4 N/A N/A N/A N/A N/A 6 Other, Ill-defined & Unk. 5 5 2 3 N/A N/A N/A N/A 1 4 All Sites Combined 395 360 156 204 34 98 63 56 70 39 M=male, F=female, AJCC Stage Grouping T, N, and M categories describe the anatomic extent of disease. Stage groupings gather cases into homogeneous categories to facilitate analysis. See glossary
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2014 Cancer
COMMITTEE
MEMBERSHIP REQUIRED PHYSICIAN MEMBERS
REQUIRED NON-PHYSICIAN MEMBERS
AD HOC PROGRAM MEMBERS
Cancer Committee Chair/CoChair • Vincent Bjorling, MD • Jason Walsh, MD, FACS
Cancer Program Administrator • Jeff Kriewald, B.S. RT(R)(T)
Todd Sorensen, MD, MS President/CEO Regional West Health Services
Cancer Liaison Physician • Gitesh Chedda, MD • Jason Walsh, MD, FACS Medical Oncology • Vincent Bjorling, MD • David Johnson, MD, FACP • Regine Leconte, MD Radiation Oncology • Mark Hartman, MD Pathology • Peter Schilke, MD, FCAP • Randall Williams, MD, FASCP Diagnostic Radiology • Gitesh Chedda, MD • Stephen Johnson, MD, PhD Surgery • Jason Walsh, MD, FACS • Jason LaTowsky, MD
Certified Tumor Registrar • Cindy Keller, CTR • Joann Cervantes, CTR Social Worker • Carol Diffendaffer, PMHP, PMSW, OCW-C • Jodi Willats, MSW Quality Management • Margo Ferguson, MT (ASCP) • Kris Henkel, RN
Shirley Knodel, RN, MS Chief Nursing Officer/Vice President Patient Services Jan Taylor, MT (ASCP) Vice President Ancillary Services John Kabalin, MD, FACS Urology Chris Buhr, RN Nursing Services
Oncology Nursing • Sue Schoeneman, AOCNP, ACNP, MSN • Kim Croft, BSN, RN
Kim Croft, BSN, RN Cancer Services
Palliative Care Services • Connie Beehler, MD, MS, FAAHPM • Deborah Moore, APRN-NP
aren Johnson, RD, CSO, LMNT K Food Service
Nichole Griffith, PT, DPT Rehab Services
Jill Koch ACS Representative elsey Kriewald, Pharm.D, RPH K Pharmacy Sharon McKinney, Director Imaging Services Department Amy Potts Medical Staff Office Paulette Schnell, RN Community Health
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REGIONAL WEST MEDICAL CENTER
Cancer Program 2015 Goals
• A clinical goal of expanding the family history screening conducted through Sally Jobe and Mary Frievogel to include clinics outside of the cancer service line, i.e. Family Medicine. This will focus primarily on getting additional patients who do not have a diagnosis of cancer to complete the genetic risk assessment questionnaire.
• The programmatic goal will be to re-establish an in-house smoking cessation program.
2014 Accomplishments
• Development of Stereotactic Body Radiation Therapy (SBRT) program. This therapy can be used for many types of patients and can reduce the treatment time and course duration. Implementation will involve the purchase of equipment and development of a streamlined program that is easy for patients to access. As part of Phase 1 for the SBRT program, a CT scanner will be purchased for the cancer center in 2015.
• An in-house marketing campaign with a focus on public and internal educational forums, as well as external presentations sponsored by the Regional West Foundation, all of which will draw attention to the quality cancer treatment services available at Regional West.
-S mall in-services may be utilized at various department staff meetings in order to help highlight the Cancer Services program.
-T he Regional West Medical Center campus Intranet will be utilized for advertising and informational items.
-E xternal quarterly presentations where different disciplines share information about their specialty may also be planned.
-A promotional billboard was placed on Highway 71 in June 2014. The new slogan for the cancer program is “Health, Hope, Healed.”
- A new website will be going up in first quarter 2015.
-W ith assistance from Marketing, an informational brochure is currently being created.
- A video commercial for the Cancer Treatment Center has been created as well.
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n
DIAGNOSED
PROSTATE CANCER DIAGNOSED 2012
National Cancer Data Base: Benchmark Reports Community Hospitals All states – 411 hospitals (9,217 cases) Hospitals in Nebraska – 5 hospitals (193 cases) Regional West Medical Center (30 cases)
Diagnosis Year 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Reg. West Nebraska All States
2008
2009
2010
2011
2012
AJCC Stage
100%
Reg. West
80%
Nebraska
60%
All States
40% 20% 0% Stage I
Stage II
Stage III
Stage IV
Unknown
Treatment Modalities Surgery Only
Radiation Only Reg. West Radiation and Hormone
Nebraska All States
Hormone Therapy Only Other Specified Therapy No Treatment 0%
10%
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20%
30%
40%
50%
60%
70%
80%
90%
100%
2012
PROSTATE CANCER
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Radiation Treatment FOR PROSTATE CANCER
By Mark Hartman, MD, Radiation Oncologist: Regional Radiation Oncology Care
Radiation remains a practical and robust definitive treatment for men with all stages of prostate cancer, the most common malignancy diagnosed in American males.
Mark Hartman, MD
External beam radiation therapy continues as the mainstay of radiation-treated prostate cancer. The most common type of external beam radiation is called “intensity modulated radiation therapy,” or IMRT, delivered under daily image-guidance. This type of radiation regimen is given over the course of up to nine weeks. There are currently two other external beam radiation techniques under investigation. One is called “hypofractionated radiation,” which is a form of daily treatment giving higher doses over four to six weeks, compared to a more standard treatment time of seven to nine weeks. Stereotactic body radiation therapy (SBRT) is a technique for treating cancers in five or fewer treatments at substantially higher doses. Hypofractionated and stereotactic radiation are currently being evaluated for long-term data and may be considered for certain patients. Brachytherapy, or more commonly referred to as “implant” radiation, is generally utilized in low to moderate grade localized prostate cancer. Brachytherapy can also be utilized in combination with external beam radiation in higher-grade localized prostate cancer. Depending on aggressiveness, size, and stage of one’s prostate cancer, patients may benefit from adding hormone therapy in the form of LHRH agonists, LHRH antagonists, and androgen receptor inhibitors to the radiation. Hormone therapy lowers testosterone production. Testosterone is a hormone that plays an important role in prostate cancer progression. It may be used, together with radiation therapy, before radiation to shrink the tumor and also after radiation has been completed. Hormone therapy is generally given to patients by their urologist. For metastatic prostate cancer patients, external radiation therapy is targeted to be delivered to a specific area where cancer is known to be located and causing symptoms. In some cases, your doctor will place a radioactive substance into the bloodstream. This is called a radiopharmaceutical and it works to attack cancer cells in all bones by floating in the blood stream and being delivered to cancer cells inside the bones.
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“ OUR GOAL IS TO OFFER PEOPLE THE
KNOWLEDGE
and the tools to deal with cancer and let them get back to living their lives.” – Mark Hartman, MD
In general, prostate cancer patients seem to tolerate radiation therapy very well. Because surgery and radiation can both be equally effective curative treatments for prostate cancer, it is important to review all of your treatment options. Ask your urologist about surgery and your radiation oncologist about radiation therapy. Our urologists and radiation oncologist work closely with prostate cancer patients at Regional West Medical Center. Learn about the risks and benefits of both to see what best meets your goals balancing cure and quality of life.
References: • www.RTanswers.org. • www.MedicineNet.com.
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Prostate Cancer SURGICAL TREATMENT OPTIONS
By Andrew Jahoda, MD, Urology, Regional West Physicians Clinic-Urology and John Kabalin, MD, FACS, Urology, Scottsbluff Urology Associates, PC A patient with newly diagnosed, clinically localized prostate cancer has several treatment options to consider. While on the surface it may sound like an advantage to have so many options, the reality is the reason we have so many different treatment avenues is because we have not developed a perfect treatment. The problem does not lie in efficacy. Prostate cancer is very treatable and relatively few men die of the disease in today’s era. The disadvantage of treatment options for prostate cancer is actually the side effects associated with treatment. A typical patient compares not the efficacy of treatment options, but rather which side effect profile he wants to risk. Andrew Jahoda, MD
In response to the side effect profiles of treatment and the realization that prostate cancer is likely being over-treated, active surveillance has come into vogue in the last several years. Men who have low volume, low-grade disease are candidates to opt for no intervention. Several protocols suggest surveillance options that typically involve PSA testing and rectal exams at routine intervals as well as repeating a prostate biopsy. Some men may live the rest of their natural lives without needing cancer treatment. For others, their disease may progress and they may require treatment. The purpose of such strict surveillance is to ensure that the patient undergoes definitive curative treatment when the cancer is still localized if it shows signs of potential growth.
Hormone therapy
John Kabalin, MD, FACS
Another treatment option for prostate cancer is hormone therapy. Hormones essentially make the cancer dormant, but this therapy does not kill cancer cells and does not provide a definitive cure, so its use is limited. Typically, hormone treatment lasts about three years on average before a patient becomes resistant to treatment. Typical side effects include hot flashes, fatigue, and decreased sexual function, although the majority of men tolerate treatment well.
Radiation therapy, surgery, and cryotherapy For men who desire a curative treatment, three general options exist: radiation therapy, either external beam or brachytherapy; surgical excision via either a traditional incision or robotic surgery; and cryotherapy. The goal of these treatments is to kill all of the cancer and provide a cure for the patient. Common side effects among all of these treatments include urinary incontinence, erectile dysfunction, and irritative urinary symptoms. In regards to surgical excision of the prostate, the trend is moving towards a minimally invasive procedure assisted by a da Vinci surgical system, often referred to as a robotic prostatectomy or da
24 | 2014 Cancer Services Annual Report
“ PROSTATE CANCER IS VERY
TREATABLE
and relatively few men die of the disease in today’s era.” – Andrew Jahoda, MD
Vinci prostatectomy (DVP). This procedure is done under general anesthesia and requires a one or two night stay in the hospital. Surgeons perform the procedure and no robots are involved that could potentially mitigate or eliminate human error. The potential upside of surgical removal is that if all of the cancerous and prostatic tissue is removed and the cancer was confined to just the prostate, there is no chance that the cancer can recur in the future. With any surgical procedure, patients risk bleeding, infection, cardiac, or pulmonary events. Overall, DVP is very safe and the mortality rate of the procedure is less than one percent. About one out of every 10 patients requires a blood transfusion around the time of the surgery. For any surgical procedure, about five percent of patients develop a wound infection. Other potential complications specific to prostatectomy are a bladderneck contracture and urine leak. Bladderneck contracture is scar tissue that forms in the urethra and causes obstruction of urine flow. Sometimes additional surgery is required to cut this scar tissue and sometimes it is a chronic condition that requires periodic catheterization to prevent the tissue from causing an obstruction. A urine leak is when the new connection of the urethra stitched to the bladder does not heal properly and urine leaks outside of the bladder and forms a pocket of urine inside the pelvis of the patient. Sometimes this pocket of urine resolves on its own and sometimes a drain is required to remove the fluid. Following a prostatectomy, 20 percent of men will have mild urinary leakage associated with activity or increased abdominal pressure. These men will leak a few drops of urine with coughing, sneezing, or laughing, which is known as stress urinary incontinence (SUI). Ten percent will have a bit more significant leakage and require a pad that may need to be changed once or twice a day. About one percent of men will have severe urinary leakage and minimal control. Unlike radiation, wherein leakage may take years to develop, surgical patients typically experience urinary leakage immediately post-op and may require
pelvic muscle exercises to improve their continence. Another potential side effect of a prostatectomy is erectile dysfunction (ED). Certainly post-surgical erectile function depends on the patient’s age and degree of ED prior to surgery, but on average, 50 percent of men suffer from ED following prostatectomy. In some circumstances, the surgeon can spare one or both neurovascular bundles to improve this rate, but many factors may limit this possibility. Many studies have compared DVP to traditional open prostatectomy. Surprisingly, DVP offers little tangible benefit. With a DVP, patients spend slightly less time in the hospital. They also have less blood loss but have no difference in blood transfusion rates compared to open removal of the prostate. However, the DVP procedure is still in its infancy. As surgeons gain more experience and refine the techniques, hopefully continence, potency, and cancer control will be perfected. A minimally invasive surgical option for select prostate cancer patients is cryotherapy, or freezing of the prostate. Cryotherapy is done under general anesthesia and is typically an outpatient procedure. This procedure historically has been wrought with complications, but recent advances in technique make it a safe and effective treatment with very few complications. Incontinence rates following cryotherapy are less than one percent. Also, irritative voiding symptoms typically associated with radiation are uncommon with cryotherapy. The tradeoff is that the rate of erectile dysfunction after cryotherapy approaches nearly 100 percent. Additionally, because the technique is relatively new and not done mainstream as of yet, typically cryotherapy is reserved for patients with special circumstances, such as post-radiation failure. But it is a primary treatment option for people who want a minimally invasive technique with a good side effect profile and are not concerned about preserving erectile function. But studies are still needed to establish long-term efficacy.
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Glossary of Terms AJCC STAGE:
American Joint Committee on Cancer Staging Scheme using tumor size, node involvement and metastases to distant sites, T=primary tumor size; N=regional lymph node involvement; M=metastasis or distant spread.
AJCC STAGE GROUPINGS (FOR MOST SITES): Stage 0: Carcinoma in-situ
Stage I:
Localized carcinoma
Stage II: Limited local extension and/or limited regional lymph node involvement
Stage III: More extensive local extension or regional lymph node involvement
Stage IV: Involvement of distant sites
ANALYTIC: Cancer cases initially diagnosed and /or having received all or part of the first course of treatment at Regional West Medical Center.
FIRST COURSE OF TREATMENT: Planned definitive therapy initiated within four months following initial diagnosis.
NCDB: National Cancer Data Base.
OBSERVED SURVIVAL RATE: The literal survival rate from counting each case in the Registry.
STAGE GROUPING PURPOSE: T, N, and M categories describe the anatomic extent of the disease. Stage grouping gathers cases into homogenous categories to facilitate analysis.
UNKNOWN: Tumor is said to be unknown when the stage cannot be determined from the medical record or a medical authority.
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For additional copies Call: 308.630.2421 Write: Regional West Medical Center Cancer Treatment Center 3911 Avenue B, Suite G100 Scottsbluff, NE 69361 Attention: Cindy Keller, CTR Cancer Registry Coordinator Email: Cindy.Keller@rwhs.org Access the report at www.rwhs.org 2014 annual report published November 2015 Teresa Clark, Editor
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CANCER SERVICES
3911 Avenue B Scottsbluff, NE 69361 308.635.3711 rwhs.org