2004 Annual Report Cancer Committee Saint Francis ...

2004 Annual Report Including 2003 Cancer Registry Statistical Review American College of Surgeons

Cancer Committee Saint Francis/Mount Sinai Regional Cancer Center

Saint Francis Hospital and Medical Center 114 Woodland Street Hartford, Connecticut 06105 860-714-4000 www.saintfranciscare.com

CANCER COMMITTEE – 2004 MEMBERSHIP Peter Tutschka, M.D.

Chairman/Medical Oncology

Margaret Ambrose, MPH, BSN

Manager, Quality and Outcomes

Robert Babkowski, M.D.

Pathology

George Barrows, M.D.

Pathology

Mark Belsky, MD

Family Practice

*Steven Brown, MD.

Colorectal Surgery/Cancer Liaison

Patricia Daigneault

Cancer Registry

Paul Davern, RPh, MBA

Pharmacy

Faye Davis, M.M., C.C.S.

Medical Records

Lynn Davis, M.D.

Medical Oncology

*Judy Feret, RN, MS

Medical Oncology (Quality and Outcomes)

*Susan Gonsalves, RHIT, CTR

Cancer Registry

Sandra Gulla, RHIA, CTR

Cancer Registry

Bruce Kaplan, M.D.

Radiation Oncology

Sue Keefe, APRN

Pain/Palliative Care

Pam Krazia, RN

Hospice

Allison Laudati, RD, CD-N

Nutrition

Ann Long, RN,C, MS, CCM, A-CCC, CNA

Director, Continuum of Care Division

Allan Mayer, DO

Gynecologic Oncology

Reverend Marcus McKinney D. Min, LPC

Pastoral Care Counseling, Director

Thomas Miller, MD

Rehabilitation Medicine

Joan Moore, APRN

Clinical Nurse Specialist-Inpatient

Zia Rahman, M.D.

Medical Oncology

Carolyn Reid, R.N., M.S.

Home Care Services

Steve Rosen, RN

Administration

Frank Setter, M.D.

Anesthesiology

*Richard Shumway, MD

Cancer Case Conference Coordinator

Jonathan Sporn, MD

Research

Carolyn Tyler, M.A., R.D.

Health Promotion

Sandy Watcke, RN

Inpatient Nurse Manager

George Wislo, M.D.

Radiology

Bonnie Zebrowski, R.N.

Nurse Manager, Outpatient

*Program Activity Coordinators

The Cancer Committee meets a minimum of four times a year, as required by the Commission on Cancer. The meetings are held on Friday mornings at 7:30 a.m. in Conference Room B, 3rd floor, in the Patient Care Tower. Cancer Center Annual Report 2004

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TUMOR REGISTRY DATA 2003

ANALYTICAL SITES CNS ORAL

RESPIRATORY

DIGESTIVE

GENITO-URINARY

OTHER SITES

HEMATOLOGIC

MISC

Brain/CNS

47

Pharynx Mouth Tongue Parotid Gland/Salivary Gland Lip

8 3 8

0

Lung Larynx Other Respiratory

217 11 3

Colon Rectum Pancreas Stomach Esophagus Liver/Biliary Other Digestive Small Intestine

139 41 39 33 15 19 14 7

Prostate Bladder Corpus Uteri Kidney/Other Other female Ovary Cervix Uteri Testis Other male

162 58 65 29 29 39 10 7 2

Breast Skin/Melanoma Thyroid Endocrine Connective Tissue Eye Bone

230 40 25 0 5 2 2

Non-Hodgkin Lymphoma Leukemia Myeloma Hodgkin Lymphoma All Other Totals

Cancer Center Annual Report 2004

5

42 48 10 2 32 1448

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TUMOR REGISTRY

The Cancer Registry was part of the survey process conducted by the Commission on Cancer of the American College of Surgeons and contributed to the achievement of a three-year accreditation award. While part of the Cancer Program at Saint Francis Hospital and Medical Center, the registry adds to the continuity of care through accurate and consistent documentation of data. The Registry data is used for research, assessment of treatment modalities and special studies. As required by law, cancer cases are reported to the Central Registry at the State of Connecticut. The Cancer Registry is managed by the Assistant Director of Health Information Management, a Coordinator, Abstractor and Technician. Cancer cases are accessioned into the registry, abstracted, reported to the State of Connecticut and annual follow-up is maintained on our analytic cases. Since our reference date of January 1, 1998, 10,539 cases have been accessioned. A total of 1,642 cases were accessioned in 2003; 1,448 are analytic cases (88%) and 194 are non-analytic cases (12%). Analytic cases are cases that were diagnosed and the first course of treatment was given at SFHMC. There was an increase in non-analytic cases due to assigning cases where the pathology report is read at SFHMC and the patient does not enter the hospital at any time for diagnosis or treatment. The five major sites of cancer at SFHMC are Breast, Lung, Colon/Rectum, Prostate and Bladder. These major sites account for 52% of all analytic cases accessioned in 2003. Our Cancer Committee meets on a quarterly basis and the Registry presents reports and provides data for special studies upon request. The Cancer Registry meets with the Chairman of the Cancer Committee providing an update of registry activity. In 2003, a successful software conversion upgrading the registry from a DOS based program to a windows based program took place. IMPAC is our new vendor and has provided the registry with upgrades and telephone support along with a Cancer Information Reference File. The file is a national data set collected from IMPAC’s clients to be used for comparing this facility’s experience with that of others. Registry activities for the past year include: •

Submitted data to the NCDB (National Cancer Data Base) annual call for data, years 1988, 1993, 1998 and 2003

•

Attended quarterly Cancer Committee meetings and combined Medical/Surgical and GYN Cancer Conferences on a weekly basis

•

Attended education meetings of the Tumor Registrar’s Association of Connecticut

•

Cancer Committee members participated in a random audit of 10 percent of our total annual analytic cases


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•

AJCC TNM staging system, General Summary Staging and SEER extent of disease staging system used

TUMOR BOARD The Tumor Board is a multidisciplinary meeting with emphasis on prospective management and therapeutic strategy of complex cases. The meeting takes place every Tuesday at noon in the Chawla Auditorium where an average of five cases are presented for discussion by the group. Hospital based physicians as well as private attendings participate in the development of a recommended treatment strategy for the patient’s management. The Gynecologic Tumor Board meets every Thursday in the Obstetrics Gynecologic Conference Room.


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OVARIAN CANCER STUDY A Comparison of the Data in the Time Periods 1995–1999 and 2000–2002 The deadliest cancer among women, the malignancy with the highest mortality rate, is ovarian cancer. Although not the most common of gynecologic cancers, the most frequent malignancy being breast cancer, the five year survival rate overall is less than 50%, and less than 10% for advanced stage disease. Since ovarian cancer is commonly not detected in its early stages, with only about a quarter of the patients diagnosed with Stage I disease, the outlook for most women with this malignancy is dismal. Thus, even thought only 1 in about 70 women will develop ovarian cancer in their lifetime, quite in contrast to breast cancer where 1 in 8 women will develop this disease, ovarian cancer remains a major health threat. Annually about 24,000 American women will develop ovarian cancer, and 14,000 will die annually from their disease. In Connecticut, about 300 patients are diagnosed annually with ovarian cancer (between 1995-1998, 1261 new cases or 315 annually). More than half of the patients diagnosed annually will die from the disease in any given year. (Between 1996 – 1998, the number of deaths was 522, or 174 deaths annually, mortality rate of 55%). Close to 10% of the women found to have ovarian cancer in Connecticut are diagnosed and treated at the Saint Francis Hospital and Medical Center, making this disease entity a particularly important one for the Saint Francis Cancer Center to focus on and to study longitudinally. To evaluate the possible trends that might lead to a better control of the disease in the future, the study reviewed our data during the time frame of 2000 to 2002, and compared them with the data of the time period 1995 to 1999. Between 2000 and 2002, 73 cases of ovarian cancer were seen (average 24 annually), most of them invasive epithelial carcinomas with papillary cystadenocarcinoma being the most frequent of them. Less than 5% of these tumors were either germ cell or stromal tumors. Table I shows the histological subtypes during the time frames of 1995 to 1999 and 2000 to 2002. There have been no appreciable changes in the number of patients diagnosed or in the distribution of the histologic subtypes.

Table I. Histology Papillary cystadeno-carcinoma Adenocarcinoma, NOS Endometrial carcinoma Serous surface papillary carcinoma Clear cell carcinoma Mucinous adenocarcinoma Garnulosa cell tumor Teratoma malignant Other Total


1995-1999 Cases % 42 36% 11 9% 10 8% 9 8% 7 6% 9 8% 2 2% 2 2% 26 22% 118 100%

2000-2002 Cases % 32 44% 5 7% 14 19% 4 5% 5 7% 3 4% 2 3% 0 0% 8 11% 73 100%

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Table II lists the age distribution of our patients with ovarian cancer, showing no trends in the age dependent incidence rates when comparing the time frame of 1995 to 1999 and 2000 to 2002. Since ovarian cancer is commonly a very insidious disease and usually asymptomatic, until it is in the advanced stage, the majority of patients (60%) presented with advanced disease of Stages III or IV. This reflects the national statistics, where identical data are seen. Unfortunately, when comparing the time frames of 1995 through 1999 and 2000 through 2002, there has been no change in patient distribution by stage of the disease, Table III. Despite more sophisticated diagnostic tools, for instance vaginal ultrasonography, there has been no increase in the number women diagnosed at an earlier stage (36% versus 33%), nor a decline in the number of women diagnosed at an advanced stage (59% versus 60%).

Table II. AGE 90-00 80-89 70-79 60-69 50-59 40-49 30-39 20-29 0-19 unknown Total

Table III. Stage Stage 1 Stage 2 Stage 3 Stage 4 Unknown Total

1995-1999 Cases % 1 1% 12 10% 30 24% 26 21% 23 19% 17 14% 8 7% 3 2% 0 0% 3 2% 123 100%

2000-2002 Cases % 0 0% 11 15% 13 18% 12 16% 20 27% 12 16% 5 7% 0 0% 0 0% 0 0% 73 100%

1995-1999 Cases % 28 24% 14 12% 34 29% 35 30% 7 6% 118 100%

2000-2002 Cases % 18 25% 6 8% 25 34% 19 26% 5 7% 73 100%

The standard treatment of ovarian cancer has been surgery, usually followed by chemotherapy. As indicated in Table IV, surgery has been a significant and virtually universal part of the treatment strategy for our patients, both in 1995 through 1999 and in 2000 through 2002, with 95% of patients in 2000 through 2002 and 94% of patients in 1995 through 1999 respectively undergoing surgery, either alone or in combination with chemotherapy (67% combined modality in 2000-2002 and 69% in 1995-1999). Again, no significant differences were found between the two time periods.


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Table IV. Treatment Surgery Radiation Chemotherapy Surg & Rad Surg & Chemo Surg & Rad & Chemo Rad & Chemo Surg & Chemo & Hormones Not Treated Total

1995-1999 Cases % 30 25% 0 0% 0 0% 0 0% 78 66% 0 0% 1 1% 3 3% 6 118

5% 100%

2000-2002 Cases % 20 27% 0 0% 1 1% 0 0% 47 64% 2 3% 0 0% 0 0% 3 73

4% 100%

When comparing survival data between the two time periods, (Figures 1 and 2) a trend towards improvement can be appreciated. During the study period of 2000-2002, Kaplan-Meier Curves only extend to 160 weeks (3.07 yrs), whereas the Kaplan-Meier Curves of the study period 1995-1999 show five year (260 weeks) actuarial data. When comparing the overall survival of both study populations, those from 1995-1999 and those from 2000-2002 at 160 weeks for all patients diagnosed and treated, the overall survival has increased from 46% to 56%. This encouraging trend does not appear to be a result of comparing significantly different patient populations, since both populations are equally distributed as to stage of the disease, age of the patients or other parameters, Table III. In the study period 1995-1999, 36% of patients were diagnosed at early stage (Stages I and II), whereas in 2000-2002, 33% of patients had less advanced diseases of stage 1 and 2. Similarly, the distribution of patients with advanced stage (Stages III and IV) disease was equal with 59% of patients in 19951999 showing Stage III and IV disease, and 60% of patient in study period 2000-2002 showing advanced disease of Stages III or IV. Thus, this trend may be due to other reasons and may possibly reflect improvements in treatment strategy. Although difficult to document, we attribute this positive trend to a change in treatment philosophy at our institution and to the result of a comprehensive multidisciplinary approach to gynecologic cancers. The importance of aggressive surgical debulking and meticulous surgical removal of residual disease, together with second and third look surgery procedures for optimal treatment outcome has been amply documented. Consequently, more and more patients over the years have seen optimal debulking, and the majority of patients undergoing surgery during the time frame 2000-2002 had their surgery performed by highly skilled gynecologic oncologists, or had these specialized gynecologists assist in or supervise in the surgery. Moreover, every patient has been seen in our Cancer Center Annual Report 2004

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multidisciplinary consultation clinic where in conjunction with medical oncology and radiation oncology an in depth assessment and comprehensive treatment planning was performed. As encouraging, as these results are, the long term outlook for most patients with ovarian cancer is still rather dismal. As discussed above, early detection and possibly even prevention of ovarian cancer are of paramount importance, if a meaningful control of the disease entity were to be achieved. Transvaginal ultrasonography as an early detection tool has not fulfilled its promise, nor have specialized tumor markers (e.g., CA-125) or metabolic test systems. New tools have to be found, but until then it may be possible to improve the outcome by raising the awareness levels of the physicians and other healthcare providers, by better informing the patients about this deadly disease and by defining and explaining risk factors for ovarian cancer, both modifiable and non modifiable risk factors. Modifiable risk factors would include parity, contraception; breast feeding, diet, or hormone replacement therapies, non-modifiable risk factors would include genetic disposition (BRCA-1, BRCA-2) or ethnic background, with socio-economic factors also playing a role. We have established a special task force of our Cancer Committee to address these issues and develop a comprehensive education and counseling strategy for the very near future.


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AGE of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in State of Connecticut - Data From 9 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Othe r

My Hosp.

Other

My Hosp.

AGE Pediatri c

1

0

0.53

0.00

16-29

4

0

2.14

0.00

30-39

6

2

3.21

5.26

40-49

33

3

17.65

7.89

50-59

40

15

21.39

39.47

60-69

34

8

18.18

21.05

70-79

42

7

22.46

18.42

80-89

22

3

11.76

7.89

5

0

2.67

0.00

38 100.00

100.00

90+ Total

187

Source: NCDB, Commission on Cancer, ACoS. Benchmark Reports, v7.0


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AGE of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in All States - Data From 279 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Other

My Hosp.

Other

My Hosp.

AGE Pediatri c

42

0

0.64

0.00

16-29

172

0

2.63

0.00

30-39

304

2

4.65

5.26

40-49

1,017

3

15.57

7.89

50-59

1,554

15

23.79

39.47

60-69

1,529

8

23.41

21.05

70-79

1,267

7

19.40

18.42

80-89

606

3

9.28

7.89

40

0

0.61

0.00

38 100.00

100.00

90+ Total

6,531



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HISTOLOGY of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in State of Connecticut - Data From 9 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Othe r

My Hosp.

Other

My Hosp.

HISTOLOGY 5

1

2.67

2.63

Adenocarcinoma, NOS

29

2

15.51

5.26

Clear Cell Adenocarcinoma, NOS

13

1

6.95

2.63

Endometrioid Carcinoma

27

6

14.44

15.79

Serous Cystadenocarcinoma, NOS

10

0

5.35

0.00

Papillary Serous Cystadenocarcinoma

54

18

28.88

47.37

Serous Surface Papillary Carcinoma

20

3

10.70

7.89

4

1

2.14

2.63

25

6

13.37

15.79

38 100.00

100.00

Carcinoma, NOS

Mucinous Adencarcinoma Other Specified Types Total

187



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HISTOLOGY of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in All States - Data From 279 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Other

My Hosp.

Other

My Hosp.

HISTOLOGY Carcinoma, NOS

232

1

3.55

2.63

Adenocarcinoma, NOS

671

2

10.27

5.26

Clear Cell Adenocarcinoma, NOS

358

1

5.48

2.63

Endometrioid Carcinoma

794

6

12.16

15.79

Serous Cystadenocarcinoma, NOS

801

0

12.26

0.00

1,653

18

25.31

47.37

Serous Surface Papillary Carcinoma

563

3

8.62

7.89

Mucinous Adencarcinoma

245

1

3.75

2.63

Other Specified Types

1,214

6

18.59

15.79

Total

6,531

38 100.00

100.00

Papillary Serous Cystadenocarcinoma



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STAGE of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in State of Connecticut - Data From 9 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Othe r

My Hosp.

Other

My Hosp.

STAGE I

27

5

14.44

13.16

II

18

8

9.63

21.05

III

95

10

50.80

26.32

IV

33

6

17.65

15.79

Unknow n

14

9

7.49

23.68

38 100.00

100.00

Total

187



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STAGE of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in All States - Data From 279 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Other

My Hosp.

Other

My Hosp.

STAGE I

1,326

5

20.30

13.16

II

504

8

7.72

21.05

III

2,718

10

41.62

26.32

IV

1,405

6

21.51

15.79

578

9

8.85

23.68

38 100.00

100.00

Unknow n Total

6,531



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TREATMENT of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in State of Connecticut - Data From 9 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Othe r

My Hosp.

Other

My Hosp.

TREATMENT Surgery Only Surgery & Chemotherapy Chemotherapy Only Other Specified Therapy No 1st Course Rx Total

41

12

21.93

31.58

107

24

57.22

63.16

19

1

10.16

2.63

4

0

2.14

0.00

16

1

8.56

2.63

38 100.00

100.00

187



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TREATMENT of Ovary Cancer Diagnosed 2003 All Reported Cases - HOSP. TYPE: Teaching/Research Saint Francis Hospital And Medical Center, Hartford, CT vs Hospitals in All States - Data From 279 Hospitals

N (cases)

% (percent)

Sum

Sum

Reported by

Reported by

Other

My Hosp.

Other

My Hosp.

TREATMENT 2,035

12

31.16

31.58

3,496

24

53.53

63.16

Chemotherapy Only

385

1

5.89

2.63

Other Specified Therapy

209

0

3.20

0.00

No 1st Course Rx

406

1

6.22

2.63

38 100.00

100.00

Surgery Only Surgery & Chemotherapy

Total

6,531



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