Hope. Healing. Offering. Cancer Treatment Center for Southern Kentucky and Barren River Regional Cancer Center. Cancer Program Annual Report 2011

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Jocelin Pitts
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1 Hope Offering Healing Cancer Program Annual Report 20 Cancer Treatment Center for Southern Kentucky and Barren River Regional Cancer Center

message from the Chairperson On behalf of the Cancer Committee, it is my pleasure to bring you the Cancer Report for 20. This year s report focuses on thyroid cancer, and Peter Hardin, M.D.

2 message from the Chairperson On behalf of the Cancer Committee, it is my pleasure to bring you the Cancer Report for 20. This year s report focuses on thyroid cancer, and Peter Hardin, M.D. gives us an in-depth look at the disease and treatment. The Medical Center has a great legacy in the battle of cancer-related illnesses. We are accredited by the American College of Surgeons as a Community Hospital Comprehensive Cancer Program. We are the longest running cancer center in the region, which displays the commitment of our physicians and staff. We have numerous programs at The Medical Center Health and Wellness Center that promote early detection through education and screenings. In addition, we host support groups for patients and their loved ones. The committee leads and coordinates the efforts of the many dedicated people at The Medical Center in their efforts to combat the disease through education, prevention, early detection and treatment. With the finest equipment, staff, physicians, and services in the region, we care for those who find themselves battling the disease. I am privileged to continue to chair The Medical Center Cancer Committee, and on behalf of the committee we present Offering Hope and Healing, Cancer Program Annual Report 20. Tage Haase, MD Board Certification in General Surgery Committee Chairperson H ope Healing Offering 2 Cancer Program Annual Report 20

3 20 Cancer Registry Report The Cancer Registry is a required and essential Weekly Tumor Conferences are also coordinated component of the Cancer Program at The Medical through the Cancer Registry office. Recently Center. It provides data management services to comply diagnosed cancer cases are discussed with Radiation with mandatory state regulations. Through the Cancer Oncology, Medical Oncology, Surgery, Radiology, Registry, recorded information for each malignancy is Pathology, and other medical specialties. Tumor maintained and is inclusive but not limited to: patient Conferences provide forums that are educational. demographics, primary site, histology, stage of disease, Attendees offer advice on treatment or further treatment, recurrence, and follow-up data. The diagnostic studies after determining the stage of the registry also provides this data to national level cancer disease. Treatment recommendations utilizing national surveillance organizations for incidence measurement. treatment guidelines are also reviewed. In 20, the Cancer Registry accessioned,007 new The Registry is staffed by two Certified Tumor cases. Of this number, 957 were analytic cases (cases Registrars (CTR) and a Registered Health Information diagnosed and/or received all or part of their first course Technician (RHIT). Their responsibilities include treatment at The Medical Center) and 58 were non- casefinding, data collection on all reportable analytic. The data base currently contains 7,3 cases. malignancies, specified hematopoietic diseases, and The Registry provides annual lifetime follow-up of every benign brain tumors that are diagnosed and/or treated patient diagnosed and/or treated for cancer at The at The Medical Center (analytic cases). All information Medical Center. A review of case distribution for 20 obtained by the Registry is submitted continually reveals that non-small cell lung cancer was the most to the Kentucky Cancer Registry and annually frequent diagnosis, with 222 new cases (27 of those to the National Cancer Data Base (NCDB). This analytic). allows comparative analysis with other hospitals or databases. Data analysis for specific sites can be done The Cancer Registry works closely with the Cancer to compare elements, such as site, demographics, Committee to maintain accreditation as a Community histology, stage of disease, treatment modalities and Hospital Comprehensive Cancer Program by the survival to other published state, regional, or national Commission on Cancer of the American College of data. This information provides the cancer program Surgeons. The hospital s Cancer Program is accredited benchmarking opportunities to patterns of care and with commendation through 203. Registry staff serves survival. For more information regarding Cancer on the Cancer Committee, which is a multidisciplinary Registry or related data, call (270) , (270)796- team that is responsible for assuring quality of care 504, or (270) and making improvements in care that is given to all cancer patients. Registrars coordinate quarterly Cancer Committee meetings, keep appropriate documentation, and ensure that the Cancer Committee meets and/or Jana Thornton, RHIT, CTR Paula Alford, RHIT, CTR Laura Cook, RHIT exceeds all COC Standards. Cancer Treatment Center for Southern Kentucky and Barren River Regional Cancer Center 3

Thyroid Cancer Epidemiology Thyroid Peter Hardin, M.D. Board Certified in Radiation Oncology Thyroid nodules are approximately four times more common in women than in men.

4 Thyroid Cancer Epidemiology Thyroid Peter Hardin, M.D. Board Certified in Radiation Oncology Thyroid nodules are approximately four times more common in women than in men. 4 Cancer Program Annual Report 20 are approximately four times more common in women than in men. Palpable nodules increase in frequency throughout life, reaching a prevalence of about 5% in the U.S. population age 50 years and older. New nodules develop at a rate of about 0.% per year, beginning in early life, but they develop at a much higher rate, about 2% per year after exposure to head and neck irradiation. By contrast, thyroid carcinoma is uncommon. For the U.S. population, the lifetime risk of being diagnosed with thyroid carcinoma is less than %. It is estimated that approximately 48,000 new cases of thyroid carcinoma were diagnosed in the United States in 20. nodules There are three main histologic types of thyroid carcinoma: differentiated (including papillary, follicular, and Hurthle), medullary, and anaplastic (undifferentiated). Of 53,856 patients treated for thyroid carcinoma between 985 and 995, 94% had differentiated carcinoma (80%-papillary, %-follicular, 3%-Hurthle), 4% had medullary, and 2% had anaplastic thyroid cancer. The 0 year relative survival rates for papillary, follicular and Hurthle cell carcinoma were 93%, 85% and 76% respectively. For these reasons most of this discussion will focus on differentiated carcinoma. Managing Differentiated Thyroid Carcinoma Managing differentiated thyroid carcinoma can be a challenge because no prospective randomized trials have been done. None the less, most patients can be cured of this disease when properly treated by experienced radiation oncologists, medical oncologists, and surgeons. The treatment of choice is surgery, whenever possible, followed in many patients by radioiodine (I3) and thyroxine therapy, External-beam radiation therapy (EBRT) and chemotherapy have less prominent roles in managing these tumors, primarily being used for recurrent or metastatic disease. Clinical Presentation & Diagnosis Differentiated thyroid carcinoma is usually asymptomatic for long periods and commonly presents as a solitary thyroid nodule. However, evaluating all nodules for malignancy is difficult because benign nodules are so prevalent and because thyroid carcinoma is so uncommon. Moreover both benign and malignant thyroid nodules are usually asymptomatic, giving no clinical clue to their diagnosis. About 50% of the malignant nodules are discovered during routine physical examinations while the other 50% are usually first noticed by the patient. Regrettably, the typical indolent nature of differentiated thyroid carcinoma often leads to long delays in diagnosis and may thus worsen the course of the disease.

5 Initial Workup For with a thyroid nodule, the first step is to measure the serum thyrotropin (TSH) level and do an ultrasound of the thyroid and central neck. Fine needle aspiration (FNA) is the procedure of choice for evaluating suspicious thyroid nodules. FNA of suspicious cervical lymph nodes should also be considered if identified on ultrasound. Suspicious criteria by ultrasound include increased central hypervascularity, hypoechoic, microcalcificatrions, and infiltrative margins. Although more than 50% of all malignant nodules are asymptomatic, the pretest probability of malignancy in a nodule increases considerably when signs or symptoms are present. Malignancy increases 7-fold if a nodule is very firm, fixed to adjacent structure, rapidly growing, associated with enlarged cervical lymph nodes, vocal cord paralysis or a patient invasion of neck structure. Surgical Management The appropriate of thyroid resection, ipsilateral lobectomy versus total thyroidectomy is very controversial for low risk differentiated thyroid carcinomas. In most clinical settings, decisions surrounding the extent of thyroidectomy should be individualized and undertaken in consultation with the patient. Total throidectomy should be considered for bilateral disease, unilateral disease greater than 4 cm or if the patient prefers this approach. No significant differences have been found in cancer-specific mortality or distant metastasis rates between these two surgical approaches. However, the 20 year frequencies of local extent recurrence and nodal metastasis after unilateral lobectomy were 4% and 9% respectively which were significantly higher than the frequency of 2% and 6% seen after bilateral thyroid lobe resection. A completion thryoidectomy is recommended when remnant ablation is anticipated or if long term follow up with serum Tg is planned. Some experts recommend completion thyroidectomy for routine treatment of tumor cm or larger because 50% of patients with cancer this size have additional cancer in the contra lateral lobe. Radioactive Iodine Adjuvant Therapy Postoperative radioiodine is recommended for patients with persistent disease, gross residual disease, tumors > 4 cm, or distant disease, or for select patients without gross residual disease who are at higher risk of recurrence, histologic features associated with a higher risk of recurrence, postoperative Tg and intraoperative findings. Thus postoperative radioiodine may be used to () ablate the thyroid remnant, which will help in surveillance for recurrent disease (2) eliminate suspected micrometastases or (3) eliminate persistent disease. Radioiodine therapy is recommended for select patients who are at greater risk for recurrence based on clinical indication, which include high risk histology, vascular invasion, and cervical node metastases. Radioiodine is not routinely recommended for patients with unifocal or multifocal papillary microcarcinomas, < cm, confined to the thyroid. Post Treatment Imaging & Assessment When radioactive iodine is given, whole body radioiodine imaging studies should be performed several days later to document uptake by tumor. Post treatment whole body imaging should also be done because 25% of such imaging shows lesions that may be clinically important, which were not detected on the diagnostic imaging. External-Beam Radiation and Surgical Excision of Metastases Isolated skeletal metastases should be considered for surgical excision or external irradiation. Brain metastases pose a special problem, because radioactive iodine may induce cerebral edema. Neurosurgical resection can be considered for brain metastases. For solitary brain lesions, either neurosurgical resection or stereotactic radio surgery is preferred. Once brain metastases are diagnosed, disease specific mortality is very high with a reported median survival of 2.4 months. Systemic Therapy Systemic therapy can be considered for tumors that are not surgical resectable, are not responsive to radioactive iodine or are not amenable to therapy with external-beam radiation treatments. Ref: NCCN Guidelines Version Cancer Treatment Center for Southern Kentucky and Barren River Regional Cancer Center 5

6 Total Cases 20 Age at Diagnosis Age at Diagnosis 20 Stage at Diagnosis Stage IVC Stage II 2 Stage IVA 3 Stage III 8 Stage Unknown Stage I 7 20 Histology Papillary Carcinoma, NOS Carcinoma, NOS Papillary Adenocarcinoma, NOS 4 Papillary Microcarcinoma Papillary Carcinoma Follicular Vari 5 20 Therapy Summary by Stage Stage Tx Type, Best Stage Group Stage I Stage II Stage III Stage IVA Stage IVC Unknown Totals Hormone Non-definitive surgery Radiotherapy Surgery Totals Daviess 20 County of Diagnosis 20 Papillary & Follicular Over 44 Years of Age Total Cases Stage I Stage III Stage IVA Stage II Stage IVC Stage Unknown 2 Muhlenberg Ohio Logan 5.62% Butler 3.2% Simpson 3.2% Grayson Warren 8.75% Edmonson 9.38% Allen 2.5% Hart Green Barren 8.75% Metcalfe 3.2% Monroe 6.25% Adair 6.25% Cumberland 3.2% 6 Cancer Program Annual Report 20

7 Cummulative Survival Rate Percent Surviving 00 Observed Survival for Cases Diagnosed in National Cancer Database Data from 425 Facilities (National) Years Observed Survival for Cases Diagnosed in The Medical Center Cancer Registry Data Years Year Year Signs & Symptoms The following are signs and symptoms of thyroid cancer, although these signs can be associated with other problems. It is important to see your doctor if you have any of these symptoms. 2 Years 3 Years Years from Diagnosis 2 Years 3 Years Years from Diagnosis 4 Years 4 Years Stage I Stage II Stage III Stage IV 5 Years Stage I Stage II Stage III Stage IV *Source: Bump, lump or swelling in the neck, sometimes growing very quickly. Pain in the front of the neck, sometimes going up to the ears Hoarseness or other voice changes that do not go away Trouble swallowing Breathing problems (feeling as if one were breathing through a straw ) A constant cough that is not due to a cold 5 Years 20 Cancer Committee Members Tage Haase, M.D. General Surgery/Cancer Committee Chair Juli McCay, M.D. Pathology/Physician Liaison Daniel Geis, M.D. Pathology/Tumor Conference Coordinator Jeffrey Brannick, M.D. Radiology Jim Gaffney, M.D. Hosparus Richard McGahan, M.D. Radiation Oncology Vidya Seshadri, M.D. Medical Oncology Paula Alford, RHIT, CTR Cancer Registry Georgena Brackett, RHIA, LCSW, FACHE, MBA Director, Health Information Management Laura Cook, RHIT Cancer Registry Sandi Feria Director, Marketing Gerri Glenn, RN Director, Quality Resource Management, Quality Improvement Coordinator Melinda Joyce, PharmD, FAPhA, FACHE Vice President, Corporate Support Services Bridget Kilpatrick, BSN, RN, OCN, NE-BC Clinical Manager, Oncology Sarah Moore Executive Vice President Elizabeth Moran Social Services Lisa Rowlett, RD, LD Food and Nutrition Services Linda Rush, RN Director, Community Wellness, Community Outreach/Education Coordinator Eddie Scott Director, Radiation Medicine and Radiological Services Jana Thornton, RHIT, CTR Cancer Registry Tammy Tinsley Representative, American Cancer Society Elizabeth Westbrook Representative, Kentucky Cancer Program Laura Williams, RHIT, CCS Manager, Coding and Tumor Registry Marianne Wilson, PT, CLT, MBA Manager, Rehabilitation Services 7

8 20 Cancer Prevention & Education Community Outreach At The Medical Center, we believe that the fight against cancer begins with empowerment knowing how to prevent cancer and how to detect it in its early stages. Through a variety of avenues, The Medical Center educates Southcentral Kentucky on the importance of cancer prevention and early detection. Health fairs and presentations are held throughout the year for business and industry through The Medical Center Worksite Wellness Program, as well as for the community through such events as the Health & Wellness Expo each January. The Medical Center Health & Wellness Center hosts weekly exercise classes, a full calendar of health education classes and free health screenings each month. Wellness Wednesdays held monthly at a local elementary school reach teachers, staff and students. To reach broader audiences, The Medical Center publishes a quarterly community newsletter, WellNews, which features a variety of topics related to cancer. Over 50,000 copies are mailed each quarter to households throughout Southcentral Kentucky. To help those with cancer and their caregivers, The Medical Center offers a Cancer Support Group which meets monthly at the hospital. The group offers health information, gives comfort, helps reduce anxiety, and provides a place for people to share concerns and emotional support. To learn more about these services, call The Medical Center Health & Wellness Center at or Cancer Treatment Center for Southern Kentucky 250 Park Street Bowling Green, KY Barren River Regional Cancer Center 03 Trista Lane Glasgow, KY

Message from the Chairperson

Message from the Chairperson I am pleased to present to you our annual report on the Cancer Program at The Medical Center at Bowling Green. We are the area s longest running Community Hospital Comprehensive