BREAST CANCER SITE STUDY REPORT By Robert O. Maganini, M.D., F.A.C.S. Breast Surgeon, Alexian Brothers Medical Group

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1 BREAST CANCER SITE STUDY REPORT By Robert O. Maganini, M.D., F.A.C.S. Breast Surgeon, Alexian Brothers Medical Group Breast cancer is the most common cancer diagnosed in women around the world. In the United States alone, an estimated 230,000 people will be diagnosed with breast cancer in Another 63,000 people will be diagnosed with the earliest form of breast cancer, Ductal Carcinoma in Situ, (DCIS). Thus, each weekday in the U.S., over 1000 people are told they have breast cancer. Despite the staggering nature of these statistics, every year for the last 25 years, the risk of dying from breast cancer has steadily decreased. This incredible achievement can be attributed to earlier detection with mammography and improved treatment for breast cancer in the form of less- invasive surgery, radiation therapy, chemotherapy, hormonal therapy, and biologic therapies. Since many disciplines are involved in treating each patient, a collaborative, coordinated approach is required to ensure each individual receives the proper recommendations, is counseled carefully regarding treatments options, receives assistance in navigating through the treatment plan to completion, and is well supported through survivorship and follow-up care. The Cancer Institute at Alexian Brothers Health System has developed a fully integrated, comprehensive, multi-disciplinary program for breast cancer care supported by dedicated nurse navigators, advanced degree genetic counselors, an oncology social worker, a nutritional specialist, clinical research, palliative care, complimentary medicine, supportive care programs, and the complete array of physician specialists utilizing state-of-the-art equipment. Together they ensure that people diagnosed with breast cancer are given the maximum opportunity for cure available. This report serves to demonstrate how the breast cancer program delivers a superior level of care to those faced with a breast cancer diagnosis. 10 The Cancer Institute at Alexian Brothers

2 Hands down, the best part of my job is my patients. I have learned so very much from them. I smile when they can t thank me enough for my help and I think of all the women that they too will help, through their support and knowledge. Debbie, breast cancer survivor and Breast Center Coordinator Health System 2012 Annual Report Alexian-Cancer.org 11

3 BREAST CANCER SURVIVAL People with breast cancer treated at The Cancer Institute at Alexian Brothers Health System can expect a superior outcome with respect to our most important measure survival. Survival can be defined in these analyses in several different ways but the commonly used standard is Overall Survival which reflects people who die from any cause, not necessarily reflecting death from breast cancer. The following graph demonstrates that women with breast cancer treated at had superior outcomes compared to the National Cancer Database (NCDB) benchmark for all stages except Stage IV. The significance of the Stage IV findings are questionable due to the smaller number of people in this category, representing less than 3% of the total number of patients. The basis for the superior overall survival seen in people with breast cancer treated at is the coordinated, collaborative care, supported by the appropriate infrastructure, which will consistently deliver superior outcomes in all aspects of breast cancer care. Once, a patient completing radiation treatment said to me you don t realize how much the staff has helped me through this. My reply to her was Yes, I do. I haven t always sat on this side of the desk, I stood right where you are three and a half years ago. Paula, breast cancer survivor and proud Alexian Brothers employee. 12 The Cancer Institute at Alexian Brothers

4 Alexian Brothers Health System Stage at Diagnosis Overall 5-Year Survival by Stage 39% 38.2% NCDB 95.8% 95.2% 93.5% 91.2% 83.5% 83% 71% 58.4% NCDB 20.8% 1 26% 24.8% 11% 8.5% 3% 3. 3% 3.9% Stage 0 Stage I Stage II Stage III Stage IV Other Stage 0 Stage I Stage II Stage III Age at Diagnosis 20.6% 10.6% Stage IV Approximately 80% of the individuals diagnosed with breast cancer in the United States are over the age of 50. A significant number of women are diagnosed between the ages of 40 and 50, representing about 15% of the total nationwide, with the balance of 5% representing people under the age of 40. Thus, despite years of controversy, women under the age of 50 remain an important group to screen with mammography for breast cancer. We continue to strongly recommend annual screening mammography for all women over the age of 40. The women under 40 years of age diagnosed with breast cancer require special consideration in their care, and within we offer a full complement of specialized services and resources necessary for this unique group. The following graph compares age at diagnosis in the Alexian Brothers Health System with the NCDB standard. One can appreciate from the graph a slightly higher number of younger patients at. This finding most likely reflects a younger demographic or general population in the communities served by. 6% Tumor Stage The American Joint Committee on Cancer (AJCC) staging system was developed to more specifically classify cancers of all types to provide for better estimations of prognosis, evaluation of cancer control measures, and to determine optimal treatment. AJCC Staging remains critically important to breast cancer care, particularly in the area of evaluation of breast cancer control measures. The stage at diagnosis can reflect the adequacy of screening in a population of women or compliance with screening recommendations. Comparison of the stage at diagnosis for people diagnosed at with the NCDB data reveals nearly identical results with 82% of women being diagnosed at Stage 0, I, or II in the Alexian system. The diagnosis of breast cancer at earlier stages also contributes to the superior survival statistics seen at. Alexian Brothers Health System Age at Diagnosis 4% % 18% % % % % NCDB 90+ 1% Health System 2012 Annual Report Alexian-Cancer.org 13

5 Stage at Diagnosis by Age The following figure examines stage of diagnosis across different age groups at in comparison to the NCDB database standard. The majority of women are diagnosed at Stage 0, I, or II at across each age group. Some variance is seen in comparison to the NCDB statistics at the extremes of the age spectrum. The most likely explanation for this finding is a smaller number of people in these categories, reducing the statistical significance. 14 The Cancer Institute at Alexian Brothers

6 STAGE AT DIAGNOSIS BY AGE Stage 0 Stage I Stage II Stage III Stage IV 4% 3 6% 4% 5% 3% 0% 10% 10% 9% 14% 8% 2 29% 31% 36% 1% 16% 52% 4% 4% 4% 8% 9% 23% 22% 6% 19% 38% 5% 8% 0% 20% 40% 12% 31% 30% 28% 31% 3 36% 42% 48% 45% 43% 26% 34% 20% 33% 23% 24% 15% 23% 21% 19% 1 15% 14% 20% 12% 3% NCDB NCDB NCDB NCDB NCDB NCDB NCDB Health System 2012 Annual Report Alexian-Cancer.org 15

7 National Accreditation Program for Breast Centers Quality Measures The National Accreditation Program for Breast Centers (NAPBC) ( is a national collection of 25 professional organizations dedicated to the improvement of the quality of care for people with diseases of the breast. These organizations include all of the national thought leaders in breast care including the American College of Surgeons, the American College of Radiology, and the American Society of Clinical Oncology. The NAPBC has developed 28 program standards and 17 program components that define accredited organizations as providing the highest level of breast care. The breast care programs at St. Alexius Medical Center and Alexian Brothers Medical Center were among the first hospitals in Illinois to receive accreditation by the NAPBC in Two of the 28 program standards are presented here reflecting the provision of more conservative methods of surgical care for breast cancer. NAPBC Standard 2.3 measures the breast conserving surgery (Lumpectomy) rate versus mastectomy. The minimum standard set by the NAPBC is 50%. In this graph, one can readily appreciate that the breast conserving rate far exceeds this standard at 81%. NAPBC Standard 2.4 reflects the provision of more conservative removal of lymph nodes from under the arm through the utilization of Sentinel Lymph Node Biopsy (SLNB) technique. SLNB was developed in the mid to late 1990 s and quickly became the standard of care for the surgical evaluation of lymph nodes in most people with breast cancer, replacing the more invasive, axillary (underarm) lymph node dissection. SLNB has spared tens of thousands of women from lymphedema (chronic arm swelling) annually in the United States. Not all people with breast cancer are good candidates for this procedure. However, the indications for the use of SLNB have continued to expand since its original development based on clinical studies such that increasingly more people with breast cancer are candidates for this less invasive procedure currently. The NAPBC does not set a benchmark or minimal standard for this measure but the figure of 80% shown in this graph is consistent with the highest quality care and reflects the impact of collaborative, coordinated care resulting from our comprehensive multi-disciplinary approach. 16 The Cancer Institute at Alexian Brothers

8 2011 NAPBC Standard 2.3 Breast Conserving Surgery NAPBC Minimum Standard 2011 NAPBC Standard 2.3 Breast Conserving Surgery A proportion of at least 50 percent of all patients diagnosed with early stage breast cancer (stage 0,1,2) are treated with breast conserving surgery, and compliance is evaluated annually by BPL ,1,2 81% Less 40 Greater 40 50% NAPBC Minimum Standard 0 SAMC ABMC 86% Standard 2.4 Sentinel Lymph Node Biopsy Axillary sentinel lymph node biopsy is considered or performed for patients with early stage breast cancer (clinical stage 1,2) and compliance is evaluated annually by the BPL NAPBC Standard 2.4 Lymph Node Surgery Sentinel Lymphy Node Biopsy 80% Axillary Surgery SAMC ABMC Sentinel Lymph Node Biopsy 20% Axillary Surgery Code 0 - None Code 2 - Sentinal Code 3,4,5 - Axillary Code 6 - Both Health System 2012 Annual Report Alexian-Cancer.org 17

9 American College of Surgeons Commission on Cancer Quality Measures The American College of Surgeons Commission on Cancer (ACS CoC) has been accrediting cancer centers to establish the highest quality cancer programs in the U.S. since The Alexian Brothers Health System cancer program recently received the highest accreditation from the CoC with eight of eight possible commendations for excellence of care. Three measures specific to breast cancer treatment are reported to the CoC through the Cancer Program Practice Profile Reports (CP3R) program. The CP3R breast measures reflect the adequacy of the program to ensure that standard recommendations for breast cancer treatment are made and actually completed. The 2011 results for these three measures are shown below. exceeds the CoC goal for chemotherapy and radiation therapy treatment and meets the goal for hormone therapy treatment CP3R Quality Performance Measures Chemotherapy Radiation Therapy Hormone Therapy COC Performance Rate Conclusion The Cancer Institute at the Alexian Brothers Health System continually strives to deliver comprehensive, collaborative care for breast cancer. As validated and nationally accepted measures of quality breast care have emerged, the multidisciplinary care offered at clearly proves to be of the highest quality. Our ongoing participation in the NAPBC, CoC, and other evolving quality assurance programs offers continued proof that our Institute provides superior levels of care to those with breast cancer both now and in the future. 18 The Cancer Institute at Alexian Brothers