St. Vincent s Bruno Cancer Center

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1 2006 Annual Report For 2005 Data St. Vincent s Bruno Cancer Center Community Hospital Compreshensive Cancer Program Accredited by American College of Surgeons Commission on Cancer

2 St. Vincent s Cancer Center Chairman s Annual Report The St. Vincent s Bruno Cancer Center experienced another year of growth in We diagnosed and managed 1,514 cancers to include 584 prostate, 288 breast, 107 colorectal, and 113 lung cases. Most of these patients were primarily treated with surgery, but over half received radiation therapy, chemotherapy, or antibody therapy and other adjuvant treatments in the Bruno Cancer Center. Everyone involved with these complex treatments, especially the patient s, appreciate how fortunate we are to have our diagnostic modalities and cancer treatments conveniently housed in the same building complex. The radiation oncology center continued to implement and expand two new state-of-the-art radiation therapy procedures introduced in The High Dose Rate (HDR) unit is a technique that combines with breast surgery to target the area where the cancer was surgically removed rather than radiating the whole breast and, in contrast to seven weeks of external beam radiation therapy, can be completed in five days. The IMRT (Intensity Modulated Radiation Therapy) program was fully implemented. In January 2005, we added the Acculoc component of IMRT for treatment of prostate cancer. This technology allows for submillimeter localization of a radiation target, thus avoiding toxicity to adjacent tissues. Finally, plans were finalized to install TomoTherapy, a highly sophisticated computerized imaging and radiation treatment equipment that combines for precise 3D imaging from CT scanning with highly targeted radiation beams. Treatments will began in The medical oncology center was bursting at the seams with activity. There were over 9,500 outpatient visits and almost 5,000 treatments (primarily chemotherapy) administered in the Bruno Cancer Center facility. The pharmacy service was expanded by the addition of a pharmacy technician, Georgeta Lazarescu, and the menu of treatments was enhanced and expanded by the utilization of breakthrough therapies like monoclonal antibodies that target specific metabolic pathways critical to cancer cell metabolism. One of the most important components of the medical oncology program, the clinical trials, remained robust. There were 114 patients who participated in one of 12 different trials using stateof-the-art drugs for the treatment of breast, colon, gastric, and kidney cancers. This program continues to give our patients access to better treatment innovations that continuously become available. Other vital services that continue to substantially enhance our program included The Breast Cancer Support Group, The General Cancer Support Group, and Camp Bluebird. Cancer screening clinics were conducted for skin cancer and prostate cancer during the course of the year. Another vital service was provided by the St. Vincent s Foundation, which generously provided funds for the patient drug assistance program. Finally, I am pleased to report that the Commission on Cancer survey team awarded us with the highest approval rating, Three-year approval with Commendations, as a Community Hospital Comprehensive Cancer Program. This designation is only awarded to comprehensive programs that meet high standards of practice in all components of service essential to provide high quality comprehensive cancer care. We are especially grateful to our cancer registry director, Sheila Grant, for shepherding us through the site inspection and approval process.

3 Cancer Committee Members James Cantrell, MD, Cancer Committee Chairman Matthew Abele, MD DERM J. Max Austin, MD GYN/ONC Mack Barnes, MD Stephen Beck, MD Sheldon Black, MD Tom Brown, MD Gray Buck, III, MD Jason Moellinger, MD John Glover, MD Jon David Holmes, MD Caroline McCall Patricia Patterson, MD Robert Pritchett, MD Jill Rutherford, MD GYN/ONC HEM/ONC OTOLARYN INMED GEN SURG URO RAD ONC ORAL/MAX PATHOLOGY PULMONARY DERM DIAGNOSTIC RADIOLOGY Sally Salter, MD Susan Salter, MD Debbie Cox, RN Edsel Davis Frank Adkins Sheila Grant, RHIA, CTR Rosalind Patterson, RHIT, CTR Nancy Lewis Bill Paullin Sarah Anne Higgins, MSW Jane Reeves, RN Diane Cherry, RN Pamela Wright, RN Jackie Doubleman, RN Lori Langner Kimberly Rider Kathy Jackson GEN SURG RAD ONC HOSPICE PASTORAL CARE QUALITY REVIEW CANCER REGISTRY CANCER REGISTRY ADMINISTRATION DIRECTOR CLIN SVCS SOCIAL SVCS MAMMOGRAPHY ONCO UNIT ONCO NURSE MGR ENTEROSTOMAL THERAPY ACS GHS RTT RAD ONC

4 St. Vincent s Cancer Program St. Vincent s Cancer Program is accredited by the Commission on Cancer (CoC) as a Community Hospital Comprehensive Cancer Program (COMP). In 2005, St. Vincent s Cancer Program was awarded with the highest approval from Commission on Cancer, a Three-year Approval with Commendation. This is awarded to facilities who voluntarily commit to providing quality cancer care to patients using the state-of-the-art technology. During the rigorous approval process, St. Vincent s underwent evaluation and review of their performance, diagnostic, treatment services, and medical staffing to ensure the best quality of care for our patients. The cancer program has five key elements that make it a successful program. The Cancer Committee leads the program by setting annual goals, monitoring activity, evaluating patient outcomes, and improving patient care. The committee also host community outreach screenings such as Prostate Cancer, Head/Neck Cancer, and Skin Cancer. In 2005, St. Vincent s Cancer Program was awarded with the highest approval from the Commission on Cancer, a Three-year Approval with Commendation. Clinical Services provide state-ofthe-art pretreatment evaluation, staging, treatment, and clinical follow-up for cancer patients seen at the facility for primary, secondary, tertiary or quaternary care. Cancer Conferences provide a forum for patient consultation through discussion of up-to-date techniques and treatment options for cancer patients, as well as educate for medical staff and ancillary personnel. The Quality Improvement program is the mechanism for evaluating and improving patient outcomes. Annually, the Cancer Committee discusses clinical areas or cancer sites to be reviewed throughout the year. As a COMP Cancer Program, each yearthe program is responsible for collecting data for two quality studies and two quality improvements. The Cancer Registry and Database is the basis for monitoring the quality of care. The Cancer Registry staff consists of 1.8 FTE and has two certified tumor registrars. In 2005, the Registry collected 1,606 new cases 1,514 of which were diagnosed and treated at St. Vincent s Hospital. The top five treated sites are Prostate, Breast, Lung, Colon, and Oral Cavity. The registry continues to exceed the standard survival rate with 91 percent. This is done by collecting follow-up data on 21,000 cases in their database on an annual basis. In efforts to maintain quality data, the cancer registry data is submitted and reviewed by the Alabama Statewide Cancer Registry each month and annually to the National Cancer Database s Call for Data annully.

5 Minor Salivary Gland Malignancies Jon D. Holmes, D.M.D., M.D., FACS Sheldon Black, M.D., FACS Introduction In the St. Vincent s 2003 Annual Cancer Report, we reported on the hospital s oral cavity cancer treatment and outcomes. That report focused on squamous cell cancers, which make up approximately 90 percent of oral cavity malignancies. This report focuses on another subset of oral cavity malignancies: cancers affecting the minor salivary glands. Although the majority of tumors affecting the minor glands are malignant (approximately percent), cancers affecting the minor salivary glands make up only around 10 percent of oral cancers and 2-4 percent head and neck cancers. Salivary glands are divided into major glands, which include the paired parotid, submandibular and sublingual glands, and minor glands, which include approximately 600-1,000 glands concentrated in the lining of the oral cavity. Minor glands are also located, to a lesser extent, in the pharynx, larynx, and paranasal sinuses. Cancers affecting the salivary glands, both major and minor, are rare, with around 3,300 new cases in the United States each year. Although the majority of tumors affecting the minor glands are malignant (approximately percent), cancers affecting the minor salivary glands make up only around 10 percent of oral cancers and 2-4 percent head and neck cancers. Because they are uncommon, the diagnosis of minor gland malignancies and decisions regarding the most appropriate treatment are difficult. Indeed, nowhere in the literature of head and neck cancer is there more confusion regarding appropriate histologic classification, treatment recommendations, and the long-term fate of patients than in regards to cancers affecting the minor salivary glands of the oral cavity. Diagnosis and Staging Diagnosis of a minor salivary gland cancer is usually made following detection of a painless mass or swelling, and biopsy. The palate and retromolar trigone areas are common sites because of the concentration of minor glands in these areas. It should be remembered that any site is possible, and mucoepidermoid cancer can even occur within the maxilla and mandible as a primary intra-osseous cancer. According to the current WHO classification, there are approximately 23 histologic subtypes of minor gland malignancies. The seven most common, and clinically relevant, include mucoepidermoid carcinoma, adenoid cystic carcinoma, adenocarcinoma NOS, acinic cell carcinoma, polymorphous low grade adenocarcinoma, carcinoma ex pleomorphic adenoma, and epithelial-myoepithelial carcinoma. Unlike major salivary glands, tumors affecting the minor glands are usually accessible for an incisional biopsy and usually do not require fine needle aspiration (FNA). An exception can be deep tumors of the floor of mouth where concerns regarding anatomical structures may make FNA a more vi-

6 able option. Pathologic diagnosis of incisional and FNA samples can be difficult, and pathologists with experience in salivary gland cancers should review the pathology. Since both the FNA and incisional biopsy are only a sampling of the entire tumor, patients must be warned that histologic examination of the entire specimen following excision may render a different diagnosis and alter the treatment plan. A classic example is a low-grade mucoepidermoid cancer diagnosed at biopsy which is changed to high-grade once the entire specimen is examined and areas of poorly differentiated tumor are identified. Once a histologic diagnosis is made, standard work-up is similar to other oral cavity cancers, and a clinical staging work-up is undertaken, which typically includes a systematic examination of the upper aerodigestive tract with nasopharyngoscopy in the office or panendoscopy in the operating room. Computerized tomography (CT) or magnetic resonance imaging (MRI) is utilized to evaluate the primary tumor, as well as evaluate the regional lymphatics for metastasis; which, although are rare in most minor salivary gland cancers, can be as high as percent in certain subtypes, such as high grade mucoepidermoid cancer. MRI is usually preferred in the evaluation of minor salivary gland cancers because of the exquisite soft tissue detail including evaluation for perineural extension. CT may be indicated, however, in cases of boney involvement. A dental examination is completed in all patients. Treatment of oral cavity cancers requires careful consideration of any remaining teeth, which should be maintained if possible to aid in the functional rehabilitation of the patient. Dental radiographs may also be used to evaluate the maxilla or mandible The cornerstone of treatment for minor salivary gland cancers is surgery. for invasion. A chest radiograph is obtained to evaluate for distant metastatic disease, more common in adenoid cystic variety. Appropriate laboratory work is obtained. The role of positron emission tomography (PET) is evolving in the staging of minor salivary gland cancers. Patients with evidence of regional metastasis are at increased risk for distant disease, and may benefit from PET. Also, the predilection for early occult pulmonary metastasis with adenoid cystic cancer makes PET useful in evaluating these patients. Clinical stage is assigned based on all data available prior to definitive therapy. Stage I and II disease is typically confined to the local area, and is associated with improved survival. Stage III and IV disease involves more extensive invasion at the primary site with invasion of deeper structures, involvement of regional lymphatics, or distant metastatic disease, and is associated with worse 5 and 10-year survival. Technological advances lead to stage migration, i.e. improved ability to detect metastatic disease with PET scans has lead to more patients being diagnosed with Stage IV disease. Although they represent a heterogenous mix, minor salivary gland cancers are staged using the same criteria as an oral cavity cancer. This is a major shortcoming of the current staging system as the behavior and prognosis of minor salivary gland malignancies varies widely and is more dependent on the histologic subtype and grade, which are not included in the stage, than the surface dimensions of the primary tumor. Despite this shortcoming, the current TNM system offers the best available means of categorizing these cancers and predicting prognosis. Treatment The cornerstone of treatment for minor salivary gland cancers is surgery. If possible, resection with tumor-free margins offers the best chance for

7 soft and hard tissues, and should be reserved for specific indications. Chemotherapy is usually reserved for palliation in cases of unresectable disease. Although there has been no demonstratable improvement in loco-regional control or survival, responders do report significant improvement in pain control. cure in the majority of cases. The planned surgical resection is typically guided by the histologic subtype and grade. For example, low-grade mucoepidermoid cancers usually respond well to local excision whereas high-grade mucoepidermoid cancers require more extensive excisions and consideration of elective treatment of the neck. Histologic features can be confusing: perineural involvement is a hallmark of both adenoid cystic cancer and polymorphous low-grade adenocarcinoma, but is associated with aggressive behavior in the former and not in the latter. Also, the presence of distant disease in certain types does not preclude surgery as certain patients can live for many months with distant disease (median of 54 months in one study of adenoid cystic cancer patients with pulmonary metastasis) if the primary site is controlled. Treating surgeons must be familiar with these nuances so that an appropriate surgical plan is developed. Controversy surrounds the role of radiation therapy in minor salivary gland cancers, and like surgery, depends on Since 2001, St. Vincent s Hospital has become a regional resource for the management of oral cavity cancers. the type and grade of cancer. Radiation therapy typically plays an adjunctive role in the post-operative setting in cases of close or involved margins, poor histologic variables (such as involvement of named nerves in adenoid cystic cancer), or regional metastasis. Radiation may also be used as sole therapy in the setting of unresectable tumors. Neutron beam therapy, a special kind of radiation therapy available at only a few centers in the United States, has shown some advantage over traditional photon radiation therapy in the management of minor salivary gland cancers. It is associated with, however, significant morbidity, such as acute and late necrosis of the Survival Survival data for minor salivary gland cancers is often difficult to interpret because of the variety of histologic subtypes included. Also, standard five year survival statistics belie the often insidious behavior of minor salivary gland cancers, and ten year survival reports paint a more realistic picture of outcomes. For example, adenoid cystic cancer affecting the minor glands is associated with a 5-year survival of approximately 50 percent and a 10- year survival of 10 percent. Typically, low-grade cancers, such as low-grade mucoepidermoid cancer and polymorphous lowgrade adenocarcinoma, have good 5 and 10 year survival, while adenoid cystic cancer and high grade adenocarcinomas carry poor 5 and 10-year survival. One of the largest published series (Spiro, 1991) reported disease specific survival of 75 percent, 62 percent and 57 percent at 5, 10 and 15 year follow-up. Despite the shortcomings previously discussed, the current TNM system does seem predictive of survival in minor salivary gland cancers. Stages I, II, III and IV were associated with 5 survival of 84 percent, 73 percent, 60 percent and 29 percent respectively, and ten year survival of 83 percent, 53 percent, 35 percent and 24 percent respectively. These statistics demonstrate further

8 Figure 1. Overall Oral Cavity Cancer vs. Minor Salivary Gland Cancers. Figure 2. Distribution by State/County Minor Salivary Gland CA 8/28/06 the need for long term (10-year) follow-up with minor salivary gland cancers. St. Vincent s Data Since 2001, St. Vincent s Hospital has become a regional resource for the management of oral cavity cancers. While oral cavity cancers are rare compared to other malignancies, ranking number nine in cancers affecting males and not making the top 10 in cancers affecting females, oral cancer ranks in the top 5 malignancies treated at St. Vincent s. Coincident with the increase in oral cavity cancers overall, the number of minor salivary gland cancers treated at St. Vincent s has increased (Figure 1). The proportion of minor salivary malignancies to oral cavity cancers is consistent with previous reports, but the number and variety of minor salivary gland cancers treated at St. Vincent s is unusually large, and rivals that of the larger reported series. Ord et al published a series of 61 cases of minor salivary gland cancers seen over a 10-year period (Ord, 2002). Since 2001, we have seen 37 minor salivary gland cancers, and here report 26 with complete data treated at St. Vincent s Hospital Females outnumbered males 16 to 10, and the majority of patients were between 50 and 70. The majority of patients were referred from outside Jefferson Couty, illustrating St. Vincent s role as a regional referral source for oral cavity cancer, including minor salivary malignancies (Figure 2). The majority presented with early stage disease (Figure 3). All patients received surgery as their initial therapy. Radiation was used in an adjunctive role as discussed previously. Histologic breakdown was consistent with recent reports, with Figure 3. Stage at Presentation

9 mucoepidermoid cancer by far the most common type (Figure 4). In general overall survival was consistent with clinical stage despite the short-comings discussed previously. Figure 4. Breakdown by Histologic SubType Conclusion Although minor salivary gland cancers of the oral cavity are rare, St. Vincent s Hospital s increasing role as a regional referral center for oral cavity cancer is making their diagnosis and management increasingly common. Physicians should be familiar with their diagnosis, treatment and prognosis. 5-YEAR SURVIVAL RATE BY STAGES REFERENCES: Cancer Facts & Figures 2004-American Cancer Society. American Joint Committee on Cancer (AJCC) Staging Manual, 6th Ed.-J.B. Lippincott Co.-Philadelphia, PA 1997 International Classification of Disease for Oncology 3rd Ed-World Health Organization-Geneva, Switzerland, IMPATH, Cancer Information Reference File, 2004

10 5-YEAR SURVIVAL RATE BY STAGES TOP FIVE SITES FREQUENCY 2005 In comparison to CIRF database, St. Vincent s has a higher incidence rate in Prostate and Oral Cavity cancer cases than collected in database.

11 FREQUENCY REPORT SUMMARY BY COUNTY Top five counties served were Jefferson, Shelby, Walker, Cullman, and Talladega. Of the 1606 cases treated, 114 were patients who live outside of the state of Alabama.

12 Primary Site Table PRIMARY SITE TOTAL MALE FEMALE ALIVE EXPIRED ORAL CAVITY PAROTID GLAND OTH PARTS MAJOR SALIVARY TONSIL NASOPHARYNX PYRIFORM SINUS HYPOPHARYNX ESOPHAGUS STOMACH SMALL INTESTINE COLON RECTOSIGMOID RECTUM ANUS AND ANAL CANAL LIVER GALL BLADDER OTHER BILIARY SITES PANCREAS NASAL CAVITY ACCESSORY SINUSES LARYNX BRONCHUS AND LUNG THYMUS HEART, MEDIASTINUM BONES, JOINTS BONES, JOINS, OTHER HEMATOPOIETIC SKIN SOFT TISSUE BREAST VULVA VAGINA CERVIX UTERI CORPUS UTERI UTERUS, NOS OVARY PENIS PROSTATE GLAND TESTIS KIDNEY RENAL PELVIS BLADDER MENINGES BRAIN OTHER CENTRAL NERVOUS SYS THYROID GLAND OTH ENDOCRINE GLANDS LYMPH NODES UNKNOWN PRIMARY SITE TOTAL Data as of

13 St. Vincent s Bruno Cancer Center Adds TomoTherapy St. Vincent s Bruno Cancer Center has a new weapon in its fight against cancer. The TomoTherapy Hi-Art System is one of the world s most advanced radiation treatment options for patients battling cancer. It provides 3-D imaging of a tumor immediately before treatment, verifying its location and reducing the chance for errors. It then delivers radiation from a 360-degree angle for a more accurate and precise treatment. St. Vincent s is one of only two cancer centers in Alabama to offer this advanced radiation treatment option. TomoTherapy is a new, revolutionary integrated cancer treatment system. It is designed to locate tumors before each treatment; deliver precise treatment with rotating beamlets; target large, small, and/or multiple lesions; and minimize radiation to healthy tissue. Using TomoTherapy, the physician can check the location of the patient s tumor before each treatment and then deliver painless and precise radiation therapy based on a carefully customized plan. TomoTherapy combines precise 3-D imaging from computerized tomography (CT scanning) with highly targeted radiation beams. It allows doctors to take a special CT scan just before each treatment, so they can verify the position of the tumor, and adjust the patient s position if necessary to make sure the radiation is directed right where it should be

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