Mercy s 2013 Cancer Program Annual Report Mercy Hospital & Medical Center is accredited by the Commission on Cancer as an Academic Comprehensive Cancer Program. This study directed by the Mercy s Cancer Committee relates to Standard 4.6: Assessment of Evaluation and Treatment Planning. Uterine cancer patients initially diagnosed at Mercy are compared to their national counterparts. Incidence, screening, demographics, stage at presentation, navigation, initial course of treatment, survival, nutrition and survivorship will be analyzed. Mercy Five Most Common Female Sites Mercy 2012 vs 2013 ACS Estimates 53% 4 29% 2 14% 8% 9% 6% 4% 3% 4% 2% 3% Breast Colon & Rectum Lung Uterus Lymphoma Kidney Incidence The American Cancer Society estimates that 49,560 1 new uterine cancers will be diagnosed in the U.S. in 2013, accounting for 3% of total estimated new cases. Uterine cancer is the most common gynecologic malignancy diagnosed in the United States. The incidence of uterine cancer has been rising and may be partially attributable to trends in both the aging of the population and increasing obesity. Uterine cancers accounted for 3% Mercy s analytic caseload in 2012 but preliminary registry data review exhibits an increase in 2013 incidence. 1 Cancer Facts & Figures 2013 pg 4 Uterus Race/Ethnicity Mercy 2007 to 2012 vs NCDB 2011 9 8 7 4 2 79% Mercy 2007 to 2012 NCDB 2011 55% 9% 6% 6% 5% White Black Hispanic API Demographics As seen above, over of women diagnosed with uterine cancer at Mercy Hospital are African American. This is more than 5 times the national statistics where Black women are through to represent between 7- of all new cases. Uterine cancer is also an area of significant health disparity, possibly due to factors such as delays in care, differences in surgery utilization, and more aggressive tumor types (4-5). This disparity persists even when controlled for stage and treatments. African American women are more likely to die from their disease; they represent 7% of all new cases, but 14% of deaths. According to national data, the 5-year survival rate for African American women is 7 compared to 90+% for white women. African American women with advanced stage disease have a 31% 5-year survival compared to 58% for white women (6). These statistics are compounded by higher rates of obesity, diabetes and cardiac disease in African American women. The demographic profile of the Mercy hospital cohort also likely affects difference in survival which will be reviewed later.
Uterus Stage at diagnosis Mercy 2007 to 2012 vs NCDB 2011 8 7 4 2 7 52% 19% 2 9% 12% 5% 7% Stage I Stage II Stage III Stage IV Mercy 2007 to 2012 NCDB 2011 Stage at Diagnosis Nationally, the vast majority of patients diagnosed with uterine cancer with Stage I disease limited to the uterus while a smaller proportion will present with advanced stages: Stage III due to involvement of vagina, adnexa or regional lymph nodes or Stage IV involvement of upper abdomen, liver, lung or other distant sites. As seen in this chart, the women diagnosed at Mercy hospital are a high risk cohort in comparison as approximately 4 will present with advanced stage at initial diagnosis. Education of patients, primary care providers, emergency room providers about the symptoms of uterine cancer such as postmenopausal vaginal bleeding to trigger rapid referral for gynecologic or gynecologic oncology evaluation by endometrial biopsy will be emphasized to try to improve this disparity in our high risk population. Uterus Histology Mercy 2007 to 2012 vs NCBD 2011 10 8 4 84% 73% 2 Adenocarcinoma Sarcoma 2% Mercy 2007 to 2012 NCBD 2011 Histology The distribution of histology types seen at Mercy Hospital compared to the NCDB demonstrates that there is a higher percentage of sarcomas which are a more aggressive type of uterine cancers associated with higher stage at presentation, higher recurrence risk and worse overall survival in compared to most of the adenocarcinoma cancers. This subtype is also found in increased frequency in African American women and may contribute to the racial disparity seen in overall survival.
Uterus Cancer Analytic Cases 2007 to 2012 BMI / Cardiovascular Disease BMI > 25 84% BMI > 25 with cardiovascular disease 45% BMI < 25 16% BMI < 25 with cardiovascular disease 58% 2 4 8 10 Percentage of patients Co-morbid Conditions Most women with endometrial cancer are likely to be diagnosed early and cured of their disease (1). Despite a positive cancer outcome, the major risk factors for this cancer, which include obesity and diabetes, persist long after the cancer diagnosis, placing these women at high risk for future morbidity and mortality (2). Studies estimate that 60-8 percent of women are overweight or obese at the time of diagnosis. As seen above, the uterine cancer patients at Mercy have high rates of obesity and associated comorbid conditions such as cardiovascular disease. Such comorbid conditions are associated with poor quality of life, survival and can effect treatment options including surgery, chemotherapy and radiation. Mercy Uterus 2007 to 2012 Treatment by Stage percent of patients 90 80 70 60 50 40 30 20 10 0 83% 69% 67% 42% 17% 17% 17% 11% 8% 8% 8% 3% Stage I Stage II Stage III Stage IV Surgery Surgery & Adjuvant Chemo / Radiation No treatment Treatment 86% of Stage I patients, 83% of Stage II patients, 75% of Stage III and 92% of Stage IV patients received appropriate surgical intervention by our team of surgeons in the Gynecologic Oncology Service which is consistent with national standard of care. Surgery generally includes total hysterectomy, bilateral salpingo-oophorectomy and pelvic and/or para-aortic lymphadenectomy when clinically indicated. Stage IV patients may undergo more extensive debulking procedures with the goal for maximal cytoreduction to optimize survival. At Mercy Hospital, as many of the patients have high risk histology or higher stage disease, many will require adjuvant treatment with either chemotherapy and/or radiation. Their care is closely coordinated in a multidisciplinary fashion among the physicians in Gynecologic Oncology, Radiation Oncology and Medical Oncology. Challenging clinical cases can be presented at the hospital wide Mercy Hospital Tumor Board. A small but important proportion of patients had no treatment at Mercy hospital due to comorbid conditions, patient refusal, patient s electing for hospice care or loss of follow-up.
Uterus Observed Survival Cases Diagnosed in 2003-2006 Mercy vs NCDB Cumulative Survival Rate 120 100 95% 87% 80 93% 85% 83% 8 % 60 71% 69% % 40 20 0 0 1 2 3 4 5 Years from Diagnosis Mercy 2003 to 2006 NCDB 2003 to 2006 Mercy Observed Survival Cases diagnosed 2003 to 2006 Black vs All Other 100 80 60 40 96% 95% 78% 85% 85% 56% 79% 56% 79% 52% 20 0 0 1 2 3 4 5 Black All other Survival Endometrial cancer is also an area of significant health disparity, possibly due to factors such as delays in care, differences in surgery utilization, and more aggressive tumor types (4-5). African American women are more likely to die from their disease; they represent 7% of all new cases, but 14% of deaths. According to national data, the 5-year survival rate for African American women is 7 compared to 90+% for white women. African American women with advanced stage disease have a 31% 5-year survival compared to 58% for white women (6). These statistics are compounded by higher rates of obesity, diabetes and cardiac disease in African American women. The survival of women with uterine cancer at Mercy is compared here to the NCDB data. As can be seen, after 2 years, the survival of patients treated at Mercy is approximately lower than the national statistics. The discrepancy in survival statistics is likely to be explained by Mercy s higher risk cohort of patients who as seen in prior graphs are more likely to be African American, to have more advanced stage at presentation, and higher risk histology. In addition, multiple comorbid conditions can adversely affect performance status and greatly limit treatment options in both the adjuvant and recurrent disease setting. Cancer Navigation The journey from the diagnosis of cancer through survivorship is challenging for any patient. Cancer Navigators guide patients through the continuum of cancer care. When utilized to their full potential Cancer Navigators function as a focal point for patients and their treating physicians. Beyond assisting patients in obtaining timely diagnostic imaging, consults and treatments, navigators can facilitate communication between treating physicians and between treating physicians and support services. The Patient Clinical Navigator in Gynecologic Oncology, Carol Newsom RN (312-567-5567) helps patient negotiate the challenges of multi-modal therapy that many of these patients are facing.
Nutrition Obesity and diabetes are well established independent risk factors for the development of endometrial cancer which is the most commonly seen subtype of uterine cancer. A recent review of over 33,000 endometrial cancer survivors demonstrated that cardiovascular disease was the leading cause of death in women with low grade early stage disease. For both high and low risk endometrial cancer patients, risk of death due to cardiovascular events was higher than risk of death from the cancer after 5 years (3). Thus, a new diagnosis of endometrial cancer becomes a compelling reason and teachable moment to promote nutrition, healthy behaviors, and weight loss in individual patients and their families. Healthy lifestyle change and interventions for reducing obesity should ideally encompass diet, exercise and behavioral change (7). Cancer survivors who are overweight or obese are in critical need of such interventions. Increasingly, advocates, patients and experts focus on survivorship issues that impact quality of life, health outcomes from co-morbid conditions after a cancer diagnosis and potential effects of obesity on cancer recurrence and survival (8-9). Obesity and weight reduction via improved diet and increased physical activity are challenging but concrete targets for cancer control and prevention efforts (10). These issues are especially important in our uterine cancer survivors. Counseling on nutrition and referral for further weight management options are actively promoted in the Gynecologic Oncology surveillance visits. During their visits, patients have the option to see one of our registered dieticians and/or to receive hands on education and written materials on diet and nutrition. Survivorship Though endometrial cancer has long been understood as one of the first cancers to be understood to be directly related to obesity, interventions targeting this group of women have been surprisingly limited compared. Pilot studies in understanding health-related behaviors and the feasibility and reproducibility of interventions are needed specifically amongst African American women with endometrial cancer. To specifically address the needs of our patient population of uterine cancers at Mercy Hospital, Dr. Nita Lee, one of the Gynecologic Oncology Physicians on staff at Mercy, has developed and been awarded a Cancer Control and Population Science Grant from the American Cancer Society, Illinois Division. The 2 year pilot program (2012-2014), Endometrial Cancer Survivorship: Reducing Obesity Reducing Disparity focuses on using an endometrial cancer diagnosis as a teachable moment to address weight loss, nutrition, and healthy lifestyle among overweight and obese African American cancer survivors, their family members, and peers (social network). The program is a direct collaboration with the Mercy Center for Weight Management and recruits African American endometrial cancer survivors from both Mercy Hospital and University of Chicago Hospital to participate in the standard 16-week program offered at the Mercy Center for Weight Management. The research study will be a pilot intervention to recruit women, follow them throughout the course of this formal program and assess change throughout via both surveys and focus groups and through collection of bio-physical markers. The long term goal is to develop a sustainable program addressing critical intersection of obesity, racial disparities and cancer survivorship in women with a history of endometrial cancer. To learn more about this research program and efforts in Uterine Cancer Survivorship, Dr. Nita Lee or Carol Newsom, RN can be reached at 312.567.5567. Nita Karnik Lee MD, MPH Board Certified OB/GYN & Gynecologic Oncology Daniel Kacey, MD Cancer Committee Chairman Daniel Vicencio, MD Cancer Liaison Physician
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