NEWS A Publication of Vantage Oncology, Tri-State Radiation Oncology Centers - TROC

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1 Oral, Head & Neck Cancer Screening Conducted Dr. Mark Logan, Midwest ENT Surgery 25 Patients Required Routine Follow up w/ PCP On Thursday, April 26th Evansville Cancer Center/ Vantage Oncology hosted its first oral, head and neck cancer screening as part of OHANCAW s national awareness campaign. The screenings were conducted by board certified otolaryngologist Dr. Mark Logan of Midwest ENT Surgery, Dr. Jon D. Frazier and Dr. Noah A. Taylor, board certified radiation oncologists with Therapy Associates. Of the 38 people screened 13 were recommend for further care with their primary care physician or an otolaryngologist with two suspected neoplasm. Sex: M : 8 Sex: M : 1 Sex: M : 1 F : 17 F : 10 F : 1 Age: : 4 Age: : 0 Age: : : : : : : : : : : : : : : : : : : : 0 Hx of Smoking : 16 Hx of Smoking : 6 Hx of Smoking : 1 Hx of Drinking : 12 Hx of Drinking : 4 Hx of Drinking : 0 H & N Cancer : 6 11 Patients Required Further H & N Evaluation H & N Cancer : 3 Evansville Cancer Center/Vantage Oncology 700 North Burkhardt Road Evansville, IN Patients Required Immediate Consult for Suspected Neoplasm H & N Cancer : 0 Require Further H & N Evaluation : 29% Require Immediate Consult for Suspected Neoplasm : 5% Require Routine Follow-up w/ PCP : 66% Oral, Head & Neck Cancer Facts - Oral, head and neck cancer is the 5th most common cancer in the World. - Approximately 50,000 people are diagnosed each year in the U.S. (95,000 people including thyroid) - The death rate from oral, head and neck cancer is very high; about 43% of those diagnosed will not survive more than five years. - With early detection, survival rates are high, and side effects from treatment are at their lowest. PRESORTED STANDARD U.S. POSTAGE PAID Permit No 2054 Evansville, IN Ra d i at i o n On c o l o g y NEWS A Publication of Vantage Oncology, Tri-State Radiation Oncology Centers - TROC Vol. 1 No CONTENTS Routine PSA Screening for Prostate Cancer...pg. 1 The Role of the Medical Physicist...pg. 3 Skin Cancer Screenings...pg. 5 Oral, Head & Neck Cancer Screenings...pg. 6 Providing Radiation Therapy at: Deaconess Chancellor Center for Oncology 4055 Gateway Boulevard Newburgh, IN Evansville Cancer Center 700 North Burkhardt Road Evansville, IN Routine PSA Screening for Prostate Cancer: Should it still be Standard Practice? There has been much recent debate in both the scientific community and lay press about the value of PSA screening. Is it still standard practice? This has been quite confusing to patients, and to physicians themselves. Here at the Evansville Cancer Center, we are well aware of this debate. However, we want to make a clear consensus statement supporting continued prostate cancer screening including PSA testing, according to the American Urological Association (AUA) guidelines for age, risk, and PSA level as described below. Our aim of this article is to examine the origins of the PSA debate, and explain the reasons behind our strong support of PSA screening. Ultimately, however, the choice to screen is an individual decision between the patient and his primary physician or urologist. We welcome referral to a urologist, who are all well aware of this debate, for consultation to assist in this initial discussion, as well as, of course, referral for further evaluation/biopsy of screened patients based on their PSA profile or DRE findings. At the Evansville Cancer Center, after careful consideration, we recognize these concerns about routine PSA screening, and welcome further investigation into these issues. However, we strongly feel that PSA screening should continue at this time. Prostate cancer is the third leading cause of cancer mortality in men in the United States, and the second leading cause worldwide. Prostate-specific antigen (PSA) was discovered in the 1980s as one of the most important and most recognized blood markers of all cancers. It is critical for assessing disease activity of prostate cancer and associated risk level once the cancer is diagnosed, and for follow-up after cancer treatment. Its value in that role is unchallenged. In addition, in the early 1990s, annual screening of healthy men over the age of using PSA was recommended. This was due to the discovery that PSA screening results in a higher detection rate of prostate cancer than digital rectal exams only. Discovering earlier stages of prostate cancer, like almost all cancers, results in more successful treatment. PSA screening therefore was predicted to result in decreased mortality. In this era of routine PSA screening since 1990, overall mortality from prostate cancer has indeed decreased. However, routine PSA screening, which subsequently has been well adopted over the past years, has been called in question recently. Some experts in prostate cancer have spoken out directly against it. The U.S. Preventative Services Task Force (USPSTF) developed a consensus statement in 2008 stating

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3 and offering regular follow-up, an increase in early detection was found, resulting in decreased deaths from metastatic disease. We at the Evansville Cancer Center feel that this larger and better-run trial confirms a benefit to PSA screening, and screening should continue. However, we await additional follow-up of both of these trials for more clarity on the issue of PSA screening, as well as the results of the large ongoing Prostate Testing for Cancer and Treatment trial in the UK. The National Comprehensive Cancer Network (NCCN) came out with a strong statement in favor of PSA screening in August 2009, and re-affirmed their statement yearly since that time, when they published their updated NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer Early Detection. They recognized the positive ERSPC trial and the value of early detection of prostate cancer. Rather than mass screening of the whole population, they recommended appropriate counseling of patients first of the pros and cons of screening, in line with our recommendation. The American Urological Association (AUA) likewise made a consensus statement in November 2009 (AUA PSA Best Practice Statement, J Urology 2009), and updated this statement in They clearly recommend a PSA baseline at age for any man with a life expectancy of at least 10 years, and additional screening intervals and routine follow-up based on individual discussions with the patient s physician. In response to the latest USPSTF statement in late 2011, the AUA stated that they strongly oppose the task force s position, and feel that the task force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease (AUA formal comment letter to USPSTF, November 8, 2011). They also point out that the USPSTF did not have a single urologist or radiation oncologist on the panel. In light of the above evidence and debate, we recommend that each patient should have a thorough consultation with their primary physician or urologist regarding beginning, and continuing, prostate cancer screening including PSA, for the early detection of prostate cancer. Men at higher risk (African American, family history of prostate cancer) should have this discussion and begin prostate screening at age 40. Men at an average risk of prostate cancer can wait to have this discussion and then begin screening at age 50. Screening intervals once PSA testing has begun can be safely done every 2 years for a PSA 2.5 ng/ml or less, every year for a PSA 2.5 ng/ml or more, according to American College of Surgeons (ACS) and AUA guidelines. PSA threshold of greater than 4.0 ng/ml is still considered a reasonable threshold for recommending further evaluation by a urologist and biopsy. However, looking into additional factors such as PSA rise above baseline, PSA velocity, and PSA level per age, are important considerations as well, to recommend shorter screening intervals and/or further evaluation than just these above guidelines. With this article, we hope to clear up some of the recent debate on PSA screening, and show a clear consensus from our group that PSA screening has merits. A thorough discussion between the patient and their primary physician on beginning and continuing screening is appropriate for all eligible men. However, once again, we encourage referral for consultation to a urologist of any patient who would like to discuss PSA screening further, as well as referrals for advice on PSA screening intervals, and referrals for consideration of additional evaluation/biopsy of screened patients with abnormal findings. - Noah A. Taylor, M.D., Radiation Oncologist, Therapy Associates The Role of the Medical Physicist in Radiation Oncology First let s answer a preliminary question. What are medical physicists? Radiation oncology physicists are scientists trained in radiological physics, basic medical, clinical, and radiobiological sciences, as well as radiation safety. Virtually all medical physicists MS Ph.D.There are a number of medical physicists working in radiology and nuclear medicine, but the majority are trained for and primarily employed in radiation therapy. We usually work behind the scenes, dealing with technical issues such as analyzing data and testing equipment. Understandably most of our work is done outside of the presence of patients and as such we keep a lower As a problem solver physicists will often solve treatment unit issues, such as replacing a multileaf collimator (MLC) motor or interface with vendor specialists to solve software difficulties. This can significantly reduce a patients wait and/or treatment cancellations. We adjust policies and procedures to avoid treatment and software issues as well as provide feedback to vendors to facilitate improvements in quality and safety. profile than other members of the department. It is likely most patients and referring physicians are not aware of the medical physics profession and if they are, probably don t have much of a clue as too our role in the department. A great deal of technology is utilized in Radiation Oncology, probably more than any other field of medicine. Because of this technology overhead, a team is required to coordinate care, plan, and deliver treatments as well as assure those treatments are of the best possible quality.

4 As part of this team the medical physicist s responsibility, given the technology available and skills of the other members of the team, is to assure safe and accurate delivery of every aspect of the radiation therapy prescription. Although this is a nice way to wrap up and put a bow on the Physicist s Role, what does this actually mean? Well physicists are primarily responsible for performance specification, acceptance testing, and commissioning of new equipment, assisting in resource planning and allocation, development and maintenance of the department s quality assurance (QA) program and often the radiation safety program, problem solving including first-run computer, software, and treatment unit maintenance, often have a direct role in treatment planning and delivery where special treatment procedures are concerned. Physicists work closely with radiation oncologists, administrators, and other team members to replace or select new equipment and to determine appropriate equipment use. This makes a great deal of sense as we are primarily responsible for studying, testing, and commissioning new treatment units and associated equipment. We often have some budgetary responsibility, especially with regard to physics testing instrumentation. We also advise with regard to staffing levels, assignments, and have some hand in recruitment. We assist Dr. Noah Taylor, Radiation Oncologist, reviews treament planning of a prostate patient in guiding program operation and are involved in ongoing policy and with Jim Duce, Physicist procedure review. The bulk of the Quality Assurance program we design around, but do not limit to, the treatment units used in radiation therapy. Prior to first use new equipment is acceptance testing, calibrating, and commissioning. Acceptance testing usually involves the physicist and a vendor representative, typically a specially trained engineer, verifying the machine meets all predefined specifications. For calibration, physicists typically use specialized measuring equipment such as ionization chambers and electrometers to adjust the amount of radiation produced by say a linear accelerator or to determine the activity of a radiation source such as Ir-192 utilized in HDR. Commissioning typically involves gathering, analyzing, importing measured data into treatment planning systems, and verifying the output of the treatment planning systems represents reality. An ongoing program of daily, weekly, monthly, and annual tests are designed by the physicist and performed on these machines. Physicists typically oversee daily and weekly QA and directly perform monthly and annual tests. These tests include verifying and calibrating the radiation output of the treatment units, the function and accuracy of the mechanical motions of the unit, and the congruence of the mechanical and radiation aspects of the machine. Another aspect of the QA program is treatment plan and chart review. Treatment plans are created on specialized computers and associated equipment called treatment planning systems. The plans created on these systems are reviewed by the physicist to verify deliverability, quality, and accuracy, in other words, the delivery of the plan will fulfill the treatment prescription. The radiation safety program facilitates compliance with regulating and certifying agencies such as the NRC, JCAHCO, and OSHA. Often physicists serve as the radiation safety officer (RSO) or assist the RSO in managing the radiation safety program. Managing personnel radioactive monitoring, overseeing the brachytherapy program including inventory and radiation source handling, participating in the radiation safety committee, performing radiation safety surveys, and determining appropriate radiation shielding for treatment units, brachytherapy treatment rooms, source handling, and storage areas are among the duties of physicist and/or RSO. As a problem solver physicists will often solve treatment unit issues, such as replacing a multileaf collimator (MLC) motor or interface with vendor specialists to solve software difficulties. This can significantly reduce a patients wait and/or treatment cancellations. We adjust policies and procedures to avoid treatment and software issues as well as provide feedback to vendors to facilitate improvements in quality and safety. Jim Duce, Physicist, performing callibrations on the linear accellerator.

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