Understanding Cancer. Mini Med School. The Advisory Board Company. Washington, D.C.

Transcription

1 The Advisory Board Company Washington, D.C. Understanding Cancer Mini Med School Presented by Fabienne Moore, MD MPH Senior Director, Talent Development February 22,

2 Mini Med School Facilitated Training Opportunities Today s Module Trauma Care Sean Benoit, MD Cardiovascular Care TBD Cancer Care Fabienne Moore, MD MPH 2

3 Roadmap for Discussion I. Cancer Biology II. Diagnosing Cancer III. Cancer Treatments IV. Key Strategic Concerns 3

4 I Cancer Biology 4

5 Cancer Biology A Cell that Goes Wrong 5

6 Cancer Genetics Causes of Cancer VS. Familial (inherited)- Genetic Multi-factorial Environmental, Lifestyle 6

7 It only takes one mutation. BRCA gene mutations 7

8 Cancer Biology Basic Pathology 8

9 Tumor Sites Heterogeneity of Cancer Breast (SEM) Lung & Bronchus Melanoma Head & Neck Pancreas 9

10 Hematologic vs Solid Cancers Hematological Cancer (e.g.. Leukemia) Solid Cancer (e.g. Soft Tissue Sarcoma) 10

11 Tumor Classification When is it Cancer? Epithelial cells (left) are tightly interconnected in sheets by numerous cell-cell interactions; their organization is determined by the basement membrane (lower left). Benign Not invading surrounding tissue or spreading to other parts of the body.; may grow but it stays put (in the same place). Malignant Having the ability to invade surrounding tissue and spread to other locations throughout the body 11

12 Size Doesn t Matter 12

13 Benign vs. Malignant Masses Benign Mass: Smooth-edged, well-circumscribed, encapsulated, homogenous Malignant Tumor: invasive, shaggy, ill-defined borders, heterogenoous 13

14 Under the Microscope Normal Kidney Benign Tumor Renal Cell Carcinoma 14

15 Staging: How Far Has it Progressed? Tumor Classification After Biopsy, the tumor may be more accurately classified in the following method: By Tumor, which describes the invasion of cancer cells into an immediately surrounding the tumor site. Graded T to T4 By Lymph Node involvement. Graded NX to N1 By Metastasis, or distal spread of cancer cells to other tissues. Graded PM1c-M1c By Surgical Margins: Graded as R Stage 1: T1 N0 M0; T2 N0 M0 - Cancer has begun to spread, but is still in the inner lining Stage 2: T3 N0 M0; T4 N0 M0 - Cancer has spread to other organs near the colon or rectum. It has not reached lymph nodes. Stage 3: Any T, N1-2, M0 - Cancer has spread to lymph nodes, but has not been carried to distant parts of the body Stage 4: Any T, any N, M1 - Cancer has been carried through the lymph system to distant parts of the body. The most likely organs to experience metastasis from colorectal cancer are the lungs and liver. 15

16 Metastases Revisited VS. Local Cancer (e.g. Stomach Cancer) Metastases 16

17 II Diagnosing Cancer 17

18 The Big Four 2007 Estimated New Cases & Cancer Deaths in US Tumor Site Incidence Rate* % of Cancer Mortality Incidence Rate % of Cancer Mortality Breast % Lung % % Prostate % Colorectal % % U.S. Cancer Statistics Working Group. United States Cancer Statistics: Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; Available at: 18

19 The Rest, 2007 Estimated Deaths Men Pancreas 6% Leukemia 4% Non-Hodgkin Lymphoma 3% Esophagus 4% Liver and intrahepatic bile duct 4% Kidney 3% Other sites 27% Women Ovary 6% Pancreas 6% Leukemia 4% Non-Hodgkin Lymphoma 3% Uterine corpus 3% Multiple myeloma 2% Brain/nervous system 2% Other sites 23% 19 Source: American Cancer Society, 2007.

20 Pediatric Epidemiology Site Male Female Total Leukemia Brain Non-Hodgkins lymphoma Kidney & renal pelvis Cancer Incidence Rates* in Children, 0-14 Years Soft tissue All sites *per 100,000 age-adjusted to the 2000 US standard population 20 Source: American Cancer Society, 2007.

21 Pediatric Epidemiology Trends in Survival, Children 0-14 Years Age Year of Diagnosis 5 Year Relative Survival Rates Source: American Cancer Society, 2007.

22 How Is Cancer Diagnosed? Diagnosis: The process of identifying a disease based on signs and symptoms Signs Shortness of breath Chest pain Loss of appetite Inflammation of lungs (pneumonia) Symptoms Wheezing Hemoptysis (bloody, coughedup sputum) Weight Loss Cough 22

23 Screening Technologies Preemptively Seeking Out Disease Mammography: Low dose x-ray system used to screen breasts for early signs of cancer PSA Test: Blood test which measures the amount of prostate-specific antigen in the blood Colonoscopy: visual inspection of the colon to screen for polyps or other masses 23

24 The Next Screening Frontier Virtual Colonoscopy: Also known as CT colonography, uses computed tomography (CT scan) to generate unique 2- and 3-D images of the colon to identify cancerous polyps Breast MRI: high-resolution MRI provides increased sensitivity for breast cancer screening in a radiation-free screening modality 24

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27 Diagnostic Technologies Ruling In (or Out) Cancer Biopsy PET A biopsy is a procedure in which a cylinder of tissue is removed from the body and tested under a microscope for signs of cancer Positron emission tomography (PET) is used to detect radiation from emission of positrons in the body. Most commonly used to detect cancer or examine effects of cancer therapy on the body 27

28 Cancer Physicians Types of Oncologists Medical Oncology Internists, certified by the American Board of internal medicine, who use medical and chemotherapeutic means to treat cancer Radiation Oncology Surgical Oncology Interventional Oncology Radiation oncologists, certified by the American College of Radiology, specialize in radiation treatment of cancers Surgical oncologists, certified by the American Board of Surgery, are trained in several types of surgical treatments, including biopsy, tumor staging, and tumor removal Interventional Radiologists specializing in image guided, minimally invasive interventions with a distinct focus on treating cancer cases 28

29 Other Important Physicians Diagnosis and Treatment Radiologists Pathologists Other Specialists Thoracic Surgeons Urologists Pulmonologists Primary Care Physicians Physiatrists Almost every doctor deals with cancer 29

30 Tumor Boards the Gold Standard Multidisciplinary approach brings all clinicians to the table Psychologist Interventional Radiologist Radiologist Hepatobiliary Surgeon Medical Oncologist Hepatocellular Carcinoma Patient Radiation Oncologist Transplant Coordinator Primary Care Physician Transplant Surgeon 30

31 Case Study Introducing Gary Hetch Gary Hetch, 55 Database administrator at small, IT firm in FL Wife, Brenda, and three children, 28, 23, and 18 Makes appointment at his physician s office after experiencing blood in urine and pain/stiffness in his back and hips Family history: Mother died of breast cancer at age 76 No previous screening tests 31

32 Was Gary at risk? Environmental Factors Long-time follower of Atkin s Diet, highprotien, high-fat Genetic Factors Family history of breast cancer (mother and grandmother) Selenium-, lycopene-, and fiber-deficient diet (Mom would have disapproved) IT: sedentary job 32

33 Gary s path to the hospital Doctor s Office Specialist s Office Hospital Gary shows up at his doctor s office, complaining of blood in urine and stiff hip/back Gary is referred to urologist for additional testing, PSA elevated Gary s urologist schedules prostate biopsy at hospital Biopsy confirms prostate cancer 33

34 Staging and Treatment Imaging tests reveal metastases to spine, confirming stage IV prostate cancer Gary works with Feretti, radiation oncologist, to establish course of care 5 treatments per week for 7 weeks at hospital s outpatient radiology center Dr. Feretti Radiation Oncologist Post-treatment, Dr. Feretti, Gary, and his primary care physician will work together to monitor progress with PSA testing 34

35 III Cancer Treatments 35

36 Wide Range of Treatment Options Oncology Treatment Technology Benchmarking by Sub-Service Line Sub-Service Line Standard Offering Advanced Offering Progressive Edge 25 th Percentile 50 th Percentile 95 th Percentile Radiation Oncology 2D-CRT 3D-CRT LDR Brachytherapy IMRT Cryoablation HDR Brachytherapy IGRT Extracranial SRS Intracranial SRS Robotic Surgery IORT VMAT Proton Beam Therapy Interventional- Surgical Oncology Open Resection Laparoscopic Resection RFA Transarterial Chemoembolization Cryoablation Hyperthermia Single Port Access Surgery Selective Internal Radiation Therapy (SIRT) MRgFUS Medical Oncology Diagnostic Imaging Chemotherapy Film Mammography Ultrasound 4-Slice CT Hormone Therapy Genetic Counseling 1.5T Fixed- Site MRI Genetic Testing Targeted Therapies Oral Chemotherapy 16-Slice CT 64-Slice 3T MRI CT PET/CT Breast MRI SPECT Full-Field CT Lung Virtual Digital Mammography Screening Colonoscopy Digital X-Ray Tomosynthesis Vaccine Therapy Gene Therapy Next-Generation CT Positron Emission Mammography Breast-Specific 7T MRI Gamma Imaging Breast SPECT/CT Tomosynthesis 36

37 Treatment Types Hormone Therapy Biologic Therapy Chemo (Medical) Radiation Surgery 37

38 Despite Innovation, Surgery Still Reins Supreme Prevalence of Use of Primary Treatment Approaches, by Tumor Site Treatment Modality Prostate NSCLC SCLC Breast Colon Rectal Bladder Cervical Uterine Renal Pelvis Melanoma Surgery X X X X X X X X X X RT X X X X X X X Chemotherapy X X X X X Hormone Therapy X X X Immunotherap y X denotes use of particular therapy in 20 percent or more of primary treatments

39 Surgical Oncology Surgery Image: Colon Cancer Surgery 39

40 Chemotherapy Chemotherapy 40

41 Clinical Trials Clinical Trials for Chemotherapy Treatments Taking Part in a Trial Understanding Cancer Research Trials Duration of Research 41

42 Radiation Therapy Radiation Therapy 42

43 Stereotactic Radiosurgery 43

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45 Proton Beam Therapy The most expensive, resource intensive medical technology 45

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49 Supportive Care Easing Side Effects Anemia Drugs Epoetin Procrit Aranesp Neutropenia Drugs Neulasta Neupogen Antiemetics Emend THC? 49

50 CAM Complementary/Alternative Medicine Acupuncture Homeopathy Chiropractic 50

51 IV Key Strategic Concerns 51

52 Rapid Rise in Oncology Costs in the Spotlight Cost of Cancer Care 29% increase $111,000 Average cost of care of patient receiving chemotherapy $93B $22,353 Average drug costs per chemotherapy patient $72B Source: American Cancer Society, available at: accessed August ; Milliman Client Report, Cancer Patients receiving Chemotherapy: Opportunities for Better Management available at: accessed August ; Oncology Roundtable interviews and analysis. 52

53 Source: Oncology Roundtable interviews and analysis. Cancer Care Ripe for Reform Essential to Streamline Care Process to Manage Future Demand Demographics Complexity of Care Provider Shortage Cost Burden Baby boomers reaching period of highest cancer incidence Increasing multi modal therapy; growing survivor needs Forecast shortage of medical oncologists. Sky rocketing cost of care per patient Variability in Utilization and Outcomes Poor Care Coordination Clinical Innovation Significant variation in treatment pattern and outcomes, lack of comparative data to inform treatment decisions Numerous transitions across providers, sites of care Emergence of new, costly treatments (e.g., proton beam therapy, targeted therapies 53

54 ABC Resources ABC Offerings Impact Oncology Services I. Oncology Roundtable II. Technology Insights III. Innovations Center 54

55 Oncology Roundtable Meeting Series Transforming Cancer Care Assessing health care reform s impact on the delivery of cancer care Organizing for accountable care Implementing clinical pathways to drive care standardization Elevating Referral Strategy Identifying key drivers of physician preference Leveraging technology to improve communication with referring physicians Enhancing outreach to community physicians Delivering on the Promise of Patient-Centered Care Expediting access to care Optimizing patient navigation models Organizing services to meet survivors needs Delivering on service excellence 55

56 For More Information Additional Resources NCI American Cancer Society ASTRO ASCO Oncolink MD Anderson NCCN Oncology Roundtable: Allison Cuff, x5713 Innovations Center: Joe McCaffrey, x6208 Technology Insights: Matt Garabrant, x6341 Or call me with any clinical issue: Lisa Bielamowicz, x