BOZEMAN HEALTH CANCER CENTER ANNUAL REPORT 2017 Gynecological Cancer Care and Treatment
Advancements in Integrated Treatment Phronsie Sprenger, LCSW Cancer is an illness that affects every part of a person s life. Some of the changes people experience are predicted, even expected; other changes are overlooked. One aspect of the gynecological cancer journey that is often disregarded, or only mentioned in passing, is sexuality and sexual intimacy. In recent years there have been significant improvements in caring for a patient s physical and emotional health. Medicine, however, has a long way to go regarding incorporating a client s sexual health into the holistic care model. These cancers and their treatment invariably affect a woman s sense of self physically, emotionally, and sexually. Patients are informed about the most common side effects of treatment, encouraged to have a good support system, and to expect some other changes the possibility of vaginal dryness, that dilators may be needed or they are told about lubricant, but not always about how to use it. Women who seek sex therapy support at the Bozeman Health Cancer Center often report experiencing a change in their sense of femininity and their sexual function following treatment. They may experience a disconnect with their partner throughout treatment, have concerns about painful sex post treatment, and a loss of desire that creates significant distress for them and their partner. Many of these women find it difficult, if not impossible, to bring up the issue of sexuality with their medical team due to stigmas and myths around sexuality. It is our hope through providing sex therapy services we can reduce some of the shame and distress that many patients experience around sexual health and treatment. 1
DATA American College of Surgeons Commission on Cancer Accreditation Bozeman Health Cancer Center is accredited by the American College of Surgeons (ACoS) Commission on Cancer (CoC). CoC accreditation means that the Cancer Center adheres to strict standards set to ensure that high quality cancer care is provided. We have been accredited through the CoC since 2009, and have been through three subsequent re-accreditation surveys in 2012, 2015, and 2018. Bozeman Health performs above recommended thresholds in measured activities, consistently exceeding the required standards. The chart below demonstrates quality measures and our reported performance related to each. ACoS also requires regular review of certain accountability and quality measures. These measures are included in the CoC s Cancer Program Practice Profile Reports (CP3R). CP3R Cervix Measures Estimated Performance Rates 2
CP3R Breast Measures Estimated Performance Rates 3
Meeting American College of Surgeons Standards for Cancer Screening Standard 4.2 - Screening Programs Each year, the Cancer Center provides at least one cancer screening program targeted to decrease the number of patients with late-stage disease. There has been a continuous need for breast cancer screenings in our community. Free clinical breast exams and screening mammograms are offered every year at our community health fairs, HealthCare Connections mobile van, and The Mammogram Project. These screening programs have been able to provide services to all types of patients, including those who have never had a mammogram and those who have exceeded the recommended time between mammograms. 4
Ovarian Cancer Treatment Kristina Hool, M.D. Ovarian cancer is the second most common gynecologic cancer and the most common cause of gynecologic cancer death in the United States. Like many other cancers, the incidence of ovarian cancer increases as patients get older. The average age at diagnosis is 63 years old. Although incidence increases with age, the lifetime risk of ovarian cancer in the United States remains low at 1.4 percent. Nearly all ovarian cancers are termed epithelial ovarian cancer because they rise from ovarian epithelial cells, which are the cells that form the lining surface of the ovary. There are other subtypes of ovarian cancer, but these are much less common. At Bozeman Health Cancer Center we offer genetic counseling and testing for women with ovarian cancer or with a family history of ovarian cancer. While lifetime risk of ovarian cancer in the general population is low, some groups of women have a much higher risk of developing ovarian cancer in their lifetime and may develop the cancer at younger ages than typically seen. These women often have inherited or genetic problems with DNA mismatch repair, or a failure to correct errors in the DNA when they occur. Examples of this include women with BRCA mutations or Lynch Syndrome, leading to a lifetime risk of up to 46 percent depending upon the specific mutation. Women with ovarian cancer and BRCA1 mutations, for example, have an average age at diagnosis of only 50 years old, with a small percentage diagnosed in their 40s. At Bozeman Health Cancer Center we offer genetic counseling and testing for women with ovarian cancer or with a family history of ovarian cancer. Because symptoms can be absent or subtle, and because there is no screening guideline for ovarian cancer, it is frequently diagnosed at an advanced stage. Over half of cases are diagnosed when the cancer has spread to other parts of the body, outside of the pelvis. For most women with ovarian cancer (regardless of stage), surgery is typically the first step in treatment. It is very rare to give chemotherapy before surgery, and is only advised if the tumor cannot be removed safely or the patient is considered too ill to survive surgery. Surgery serves more than one purpose in ovarian cancer. First, it allows the surgeon to identify all sites of cancer in a patient s body and accurately determine the cancer stage. Second, it allows for removal of as much of the cancer as possible ideally all of it so that chemotherapy given after surgery is more likely to be successful and keep the cancer from returning for as long as possible. These are extensive and very technical surgeries. We work closely with specialtytrained gynecologic oncology surgeons in Billings for these large and typically robotic-assisted surgeries. Our patients are then able to return to Bozeman after surgery and can have their post-surgery chemotherapy in Bozeman, closer to home. After surgery, most patients will have adjuvant chemotherapy. The purpose of this treatment is to delay or prevent the return of the cancer. For women whose cancer is completely removed by surgery, chemotherapy can be given directly into the abdominal cavity after surgery. This is referred to as intraperitoneal chemotherapy. Chemotherapy can also be given through IV infusion, which is used for women who have incomplete removal of tumor with surgery. With either type of chemotherapy, treatment usually lasts for approximately 18 weeks. Women are followed very closely after chemotherapy is complete, usually with blood work, scans, and frequent doctor visits. Continued on page 8 > 5
Human Papillomavirus 101 Jami Chisdak, M.D. Human papillomavirus (HPV), has received a lot of attention in the media in the past few years, and for good reason, it is very common and can cause several types of cancer. In order to prevent, diagnose, or treat cancers caused by HPV, it is important to know how it is spread, who is at risk for infection, potential recurrence of HPV infection, how to reduce chances of having an infection, and some potential treatment options. It is estimated that nine in 10 people will get an HPV infection in their lifetime. Most of the more than 100 strains do not cause cancer but are instead responsible for the common wart, such as on feet, or even genital warts (condyloma acuminate). Others can cause certain types of cancer involving the mouth or throat, vagina, vulva, cervix, penis, or anus. Thankfully, the immune system clears the virus before it creates disease in the majority of cases. However, 10-20 percent of people with HPV will get a chronic infection which is more likely associated with cancer. HPV is spread by direct skin-to-skin, or mucous membrane contact (moist tissue such as the mouth), including sexual contact of any kind (hand-to-genital contact, vaginal, anal, or oral sex). It is not contracted by touching objects such as toilet seats, from swimming pools, or from poor bathing habits. Most people do not have any symptoms of the virus and spread it unknowingly to their partner. Condoms help reduce the transmission of the virus, but a condom cannot cover the entire surface area that can transmit HPV. Minimizing the number of sexually intimate partners (any genital contact) will reduce the odds of an HPV infection. Tobacco, as with many other cancers, is also a risk factor for HPV transitioning the infected tissue into cancer. The vaccine Gardasil 9 protects against nine strains of HPV. It covers the two most common strains associated with genital warts, and the most aggressive strains for cervical cancer. The vaccine is offered to both males and females starting at age 11 or 12 years and the FDA recently extended the age limit from 26 years old to 45 years of age. If someone receives the vaccine before exposure to HPV strains covered by Average Age of Diagnosis Continued on page 8 > The median age (the age at which half of cancer patients were older and half were younger) of HPV related cancers in the United States according to the Center for Disease Control (CDC): 70 60 50 40 The CDC quotes HPV to be responsible for about: 91 percent of cervical cancers 75 percent of vaginal cancers 69 percent of vulvar cancers 63 percent of penile cancers 91 percent of anal cancers 70 percent of oropharyngeal (mouth/throat) cancers Cervical Vaginal Vulvar Penile Anal Mouth/throat 6
Pelvic Rehabilitation for Gynecologic Cancer Morgan York-Singer, PT, DPT, PRPC Pelvic rehabilitation is a specialty of physical therapy that evaluates and treats conditions that affect the lumbar, abdominal, and pelvic regions. A pelvic health physical therapist has specialized training beyond their doctorate level education in this special care. Pelvic floor muscle dysfunction can be caused by many different conditions, some benign and others more serious. Cancer treatments in the pelvic area such as chemotherapy, radiation therapy, and surgery can contribute to bladder and/or bowel dysfunction, sexual dysfunction, scarring and adhesions, generalized muscle fatigue, weakness and deconditioning. Pelvic physical therapy treatments for the pelvic floor and abdominals are based on evaluation of each patient s needs. An individual plan of care is formulated that may include therapeutic exercise, neuromuscular re-education for motor retraining, manual therapy techniques, and patient education. At Bozeman Health Rehabilitation Services, a real time ultrasound machine can be used to give the patient visual feedback for motor retraining and strengthening. Patients can also be trained on the use of dilator therapy for conditions such as vaginal narrowing or pelvic pain. Lymphedema with Gynecologic Cancers Anna Buckmaster, PT, DPT, CLT Lymphedema is an accumulation of lymphatic fluid that results in chronic swelling (edema) in the limbs and/or torso. This process can occur as a consequence of cancer and disease management (surgery, chemotherapy, radiation). Approximately 20-40 percent of women have significant lower-extremity lymphedema after surgery for gynecologic cancer, according to 2018 data. Edema can also be present in both the genital region and abdomen. Commonly reported symptoms are pain, tingling, and weakness. Unfortunately, lymphedema is under-recognized in those treated for gynecological cancers. However, if recognized early, it can be reversible and easier to manage long-term. Treatment includes a combination of manual lymphatic drainage (a light massage technique), compression (wraps, stockings, home compression pumps), exercise, and skin care. These treatments are usually provided by a Certified Lymphedema Therapist (CLT) on staff at Bozeman Health Rehabilitation Services. Quality of life is affected with reports of fatigue, functional issues (limited in work, home, and social activities), and psychological concerns such as reduced self-esteem and altered body image. Symptoms often appear within 6-12 weeks after surgery, but can begin later. 7
Ovarian Cancer Treatment Continued from page 5 Despite surgery and chemotherapy, many women with advanced stage ovarian cancer will have their cancer return. For these women, it is possible to repeat the original chemotherapy, and there are many other chemotherapies that can be attempted (many can be used alone as single drugs, some in combinations). There are newer oral agents available for recurrent ovarian cancer with the presence of specific mutations. There are also numerous clinical trials using new therapies in advanced ovarian cancer, including vaccine studies, immune checkpoint blockade, or even T-cell therapy. At Bozeman Health, we are able to offer standard chemotherapy as well as access to immunotherapy clinical trials for women with advanced ovarian cancer. Advanced ovarian cancer remains an incurable disease, but these new agents and combinations offer hope for improved survival in the coming years. HPV Continued from page 6 the vaccine, it could prevent more than 90 percent of the cancers caused by the virus. Safety assessed in 13,000 patients revealed most common adverse reactions included injection site pain, swelling, redness, and headaches. Rarely, fainting episodes and allergic reactions have happened. The vaccine, however, is not foolproof. There are over 100 strains of the human papillomavirus. The vaccine covers only nine of those. Infection, pre-cancer, or cancer can and do occur with patients who have completed the vaccine series. The vaccine also will not protect the patient from any exposures prior to receiving the vaccine. Testing for HPV is limited to sampling a woman s cervix for cancer by way of a pap smear. There is no approved HPV test for any of the other cancerassociated locations such as on the penis, vulva, anus, mouth, or throat. Cervical cancer screening occurs every three to five years from 30 to 60 years of age. HPV testing typically only every five years. Pap smears without HPV testing occur every three years starting at 21 years (unless a pap smear shows abnormal cervical cells, then it is frequently tested.) The routine HPV testing starts later as the body has a better rate of clearing the virus and not becoming a chronic infection that leads to cancer before 30 years of age. There are some circumstances where the HPV testing and pap smears continue past age 65 years, such as abnormal pap smear within the previous 10 years. Routine dental examinations can also detect precancerous signs of HPV related oral cancers. There is no cure for HPV; only treatment of the tissues that are infected and changed by the virus. This typically involves removing the tissue, using topical chemicals, or possibly radiation therapy. As with any cancer, the earlier the detection, the better the prognosis. Some of the tests, such as pap smears of the cervix, can detect the abnormal cells before they have become cancerous. Removing these cells can prevent it from becoming cancer. In summary, HPV is a very common virus. An estimated 14 million Americans will be infected at some point in their lifetime. Risk factors include multiple sexual partners (frequently associated with onset of intercourse younger than 16 years of age, or more than four sexual partners in a lifetime), tobacco use, and compromised immune system (i.e. HIV). However, most people infected with HPV will not develop cancer. The HPV vaccine reduces the cancers caused by the most aggressive strains of the virus (if they have not already been exposed) and is offered to patients from 11 to 45 years old. The median age for HPV-associated cancers is roughly in the 60s so continuing regular examinations of the mouth and genital area is recommended. 8
CANCER CENTER 931 Highland Blvd, Suite 3130, Entrance 7A Bozeman, MT 59715 Tel: 406-414-5070 Toll Free: 888-389-1000 Fax: 406-414-5029 BozemanHealth.org