DELRAY MEDICAL CENTER. Cancer Program Annual Report

DELRAY MEDICAL CENTER Cancer Program Annual Report Cancer Statistical Data From 2010

TABLE OF CONTENTS Chairman s Report....3 Tumor Registry Statistical Report Summary...4-11 Lung Study.12-17 Definitions / References.18-19 2

Chairman s Report The Cancer Committee at Delray Medical Center is pleased to present the Cancer Program 2011 Annual Report. This report highlights important cancer statistics for Delray Medical Center. Data being reported in this addition of the report reflects Tumor Registry reporting for the calendar year of 2010. The Cancer Registry staff continues to collect data on all of the patients diagnosed and treated for cancer at the hospital. The Cancer Committee, Delray s Administrative Team, and the Tumor Registry, monitors the delivery of care, for our cancer patients. The American College of Surgeon s Commission on Cancer Program Standards set the benchmark for our standards of practice, performance, and excellence. Multidisciplinary tumor boards are held at Delray to review prospective cases. In this forum, physicians, and support staff are given an opportunity to discuss newly diagnosed cancer patients in a collegial and consultative setting. This multidisciplinary team reviews data on surgery, pathology, radiology, and other diagnostic tests. We discuss the patient s case thoroughly and form a consensus and recommendation regarding the best therapeutic management of our patients. I encourage all the medical staff to participate and attend this valuable part of the oncology program. It is a learning, collaborative event which benefits our practice and our patients. In June this year, a new Oncology Program Director was appointed at Delray Medical Center. Cheryl J Wild RN, BSN, OCN, MBA, has joined the team to help grow the program and direct the care of oncology patients in this community. We are moving forward in the area of Oncology as a Focused Service line for Delray. Among many of the initiatives we are building, one very exciting endeavor is in the area of Lung Cancer. This involves a multidisciplinary, multimodality Pulmonary Nodule Clinic and Lung Cancer Center. The center will address the needs of our lung cancer population, and the patients at high risk for developing lung cancer. Our aim is to continually strive to improve the service and the options for our patient population, driving patient satisfaction, and improving patient outcomes. I am extremely thankful to everyone involved in the care of our patients, including Delray s administration, physicians, nurses, therapists, registry and all ancillary personnel. Their commitment and their efforts to continuously improve the quality of care for the patients in our community will impact this disease, and help us to better manage the quality of lives for the patients we treat. Rogelio Brito., DO Cancer Committee Chairman 3

The Tumor Registry at Delray Medical Center The Tumor Registry Department at Delray captures and follows all patients who have a diagnosis of cancer in our hospital. This department is responsible for compiling a complete summary of patient history, diagnosis, primary site/morphology, treatment, recurrences and status for every cancer patient admitted in this institution. The information becomes a key to enable doctors, researchers, and public health professionals to best understand cancer treatment and trends. The data that is maintained in the registry files is electronically reported to the Florida Department of Health through the Florida Cancer Data System (FCDS). These data are held in anonymity and shared with the Surveillance Epidemiology Endpoint Registry (SEER) program of the National Cancer Institute to generate the national cancer database. This is the database which tracks and trends cancer diagnoses throughout the nation, and helps to identify patterns and changes in cancer diagnoses among communities and patient demographics. In addition, the Cancer Registry produced reports throughout the year at the request of physicians, administration and ancillary departments for research and planning purposes. On staff here at Delray, there are two tumor registrars. Both employees are active members of the National Cancer Registrars Association. They attend national and state meetings to keep current in their field. Registry personnel serve as members of the Cancer Committee and they help to coordinate the hospital s Oncology Conferences/Tumor Boards. In addition, they help to coordinate and ensure compliance with the Cancer program s guidelines set forth by the American College of Surgeon's. The primary site table summarizes all cases entered into the Delray Medical Center s Tumor Registry in 2010 by class, gender, AJCC staging (at the time of diagnosis). This table also shows all major cancer diagnosis organ systems as well as sub-sites, within each system. The AJCC stage group only demonstrates analytic cases. Table I. 4

Table I. Primary site tabulation for total cases 2010 at DMC TOTAL CLASS SEX AJCC STAGE GROUP* A NA M F 0 I II III IV UNK N/A ALL SITES 986 640 346 509 477 89 174 65 66 99 29 118 ORAL CAVITY 13 6 7 9 4 1 1 1 0 2 0 1 TONGUE 3 1 2 3 0 1 0 0 0 0 0 0 OROPHARYNX 1 1 0 0 1 0 0 0 0 1 0 0 HYPOPHARYNX 1 1 0 0 1 0 0 0 0 1 0 0 OTHER 8 3 5 6 2 0 1 1 0 0 0 1 DIGESTIVE SYSTEM 209 149 60 118 91 8 56 26 24 28 5 2 ESOPHAGUS 16 8 8 14 2 1 3 1 0 2 1 0 STOMACH 15 9 6 10 5 1 5 2 0 0 1 0 COLON 82 70 12 46 36 4 23 15 18 10 0 0 RECTUM 28 20 8 13 15 0 9 4 2 3 2 0 ANUS/ANAL CANAL 5 3 2 4 1 2 0 1 0 0 0 0 LIVER 10 5 5 5 5 0 4 0 0 1 0 0 PANCREAS 37 20 17 18 19 0 5 2 2 10 1 0 OTHER 16 14 2 8 8 0 7 1 2 2 0 2 RESPIRATORY SYSTEM 148 106 42 63 85 1 37 9 16 30 10 3 NASAL/SINUS 0 0 0 0 0 0 0 0 0 0 0 0 LARYNX 8 4 4 5 3 1 1 1 0 0 1 0 LUNG/BRONCHUS 137 99 38 55 82 0 32 8 9 27 6 3 OTHER 3 3 0 3 0 0 2 0 1 0 0 0 BLOOD & BONE MARROW 64 24 40 37 27 0 0 0 0 0 0 24 LEUKEMIA 37 11 26 23 14 0 0 0 0 0 0 11 MULTIPLE MYELOMA 21 10 11 10 11 0 0 0 0 0 0 10 OTHER 6 3 3 4 2 0 0 0 0 0 0 3 BONE 2 2 0 1 1 0 0 0 0 0 1 1 CONNECT/SOFT TISSUE 4 2 2 3 1 0 0 0 0 2 0 0 SKIN 22 10 12 16 6 1 3 0 2 2 2 0 MELANOMA 20 10 10 14 6 1 3 0 2 2 2 0 OTHER 2 0 2 2 0 0 0 0 0 0 0 0 BREAST 51 16 35 2 49 2 7 2 2 1 2 0 FEMALE GENITAL 53 35 18 0 53 1 19 4 4 6 0 1 CERVIX UTERI 8 3 5 0 8 0 2 0 1 0 0 0 CORPUS UTERI 28 22 6 0 28 1 13 3 1 3 0 1 OVARY 13 7 6 0 13 0 1 1 2 3 0 0 VULVA 3 3 0 0 3 0 3 0 0 0 0 0 OTHER 1 0 1 0 1 0 0 0 0 0 0 0 MALE GENITAL 48 9 39 48 0 0 2 2 0 4 1 0 PROSTATE 46 7 39 46 0 0 1 2 0 4 0 0 TESTIS 1 1 0 1 0 0 0 0 0 0 1 0 OTHER 1 1 0 1 0 0 1 0 0 0 0 0 URINARY SYSTEM 158 128 30 119 39 75 21 15 5 10 2 0 BLADDER 135 112 23 104 31 73 18 14 0 7 0 0 KIDNEY/RENAL 18 12 6 11 7 0 3 1 3 3 2 0 OTHER 5 4 1 4 1 2 0 0 2 0 0 0 BRAIN & CNS 73 53 20 25 48 0 0 0 0 0 0 53 BRAIN (BENIGN) 1 1 0 0 1 0 0 0 0 0 0 1 BRAIN (MALIGNANT) 22 15 7 10 12 0 0 0 0 0 0 15 OTHER 50 37 13 15 35 0 0 0 0 0 0 37 ENDOCRINE 29 21 8 11 18 0 9 2 2 5 0 3 THYROID 20 18 2 8 12 0 9 2 2 5 0 0 OTHER 9 3 6 3 6 0 0 0 0 0 0 3 LYMPHATIC SYSTEM 75 46 29 40 35 0 19 4 9 8 6 0 HODGKIN'S DISEASE 1 1 0 1 0 0 1 0 0 0 0 0 NON-HODGKIN'S 74 45 29 39 35 0 18 4 9 8 6 0 UNKNOWN PRIMARY 33 29 4 16 17 0 0 0 0 0 0 29 OTHER/ILL-DEFINED 4 4 0 1 3 0 0 0 2 1 0 1 * AJCC stage group only demonstrates analytic cases 5

In the year 2010, a total of 986 cases were added to the registry, 640 were analytic. The graph on class of case displays the distribution of analytic cases. The majority of cases were seen in the class of case 10 category, followed by class of case 14. Graph I. Graph I. Class of Case Distribution at DMC 300 295 250 NBR OF CASES 200 150 100 50 0 170 43 53 7 14 23 13 22 00 10 11 12 13 14 20 21 22 CLASS OF CASE Class 00: First diagnosed at DMC, all treatment (or decision not to treat) elsewhere Class 10: First diagnosed at DMC and part or all of first course treatment (or decision not to treat) at DMC, NOS Class 11: First diagnosed by staff physician and part of first course treatment at DMC Class 12: First diagnosed by staff physician and first course (or a decision not to treat) at DMC Class 13: First diagnosed and part of first course treatment at DMC Class 14: First diagnosed and all first course treatment (or a decision not to treat) at DMC Class 20: First diagnosed elsewhere and all or part of first course treatment at DMC, NOS Class 21: First diagnosed elsewhere and part of treatment at DMC Class 22: First diagnosed elsewhere and all treatment at DMC 6

Bladder cancer was the leading cancer diagnosed and/or treated at DMC in 2010, representing 17.5%, followed by lung cancer with 15.4%. The third primary site was colorectal cancer with 14%. Brain and lymphoma complete the top five sites. This graph also demonstrates how DMC s data compares to national data. Graph II. Graph II. Top Primary Sites Percent (%) 20 18 16 14 12 10 8 6 4 2 0 17.5 DMC National 15.4 14.5 14 9.3 8.2 7.1 4.6 4.8 1.4 Bladder Lung Colorectal Brain Lymphoma The age group at diagnosis peaks at the 80-89 years old category with 249 cases, followed by 70-79 years old category with 178 cases. Graph III. Graph III. Distribution by Age at DMC 250 249 Nbr of Cases 200 150 100 50 0 3 7 15 61 88 178 20-29 30-39 40-49 50-59 61-69 70-79 80-89 90 or more 39 7

The distribution by gender graph indicates that both categories were very similar. There were 325 males compared to 315 females diagnosed and/or treated at DMC. Graph IV. Graph IV. Distribution by Gender Female 315 Male 325 0 50 100 150 200 250 300 350 The race distribution shows that 93% of the cancer patients were Caucasian, 4% were African American, and 3% was listed as Hispanic. Graph V. Graph V. Distribution by Race Caucasian 93% African American 4% Hispanic 3% 8

The American Joint Commission on Cancer (AJCC) TNM Staging System is used to describe the extent of the primary tumor and its spread in the body. It is utilized as a guideline to help physicians plan the most appropriate treatment and determine a prognosis. There were 328 analytic cases that were diagnosed Stages 0, I, or II. These are considered to be potentially curable. More advanced stages of cancers, stage III and IV, totaled 165 cases. Twenty-nine were staged Unknown representing cases in which certain criteria did not meet the staging standards, or there was not enough information at the time of diagnosis. The non-applicable cases (118) represent those for which there is not an AJCC staging requirement. According to the AJCC guidelines, class of case 00 is excluded. Graph VI. Graph VI. Distribution by AJCC Staging at DMC 200 150 100 50 0 Stg 0 Stg 1 Stg 2 Stg 3 Stg 4 Unk N/A Series1 89 174 65 66 99 29 118 Series2 14% 27.2% 10.1% 10.4% 15.5% 4.5% 18.4% Most patients received surgery as their first course of treatment representing 295 cases. The majority of the cases in the non-treated category are bronchus & lung cancers being diagnosed at an advanced stage. This table excludes all benign tumors and class of case 00, which reduces the total of analytic cases from 640 to 563. Table II. 9

Table II. Analytic cases by first course treatment SITE NAME TOTAL CASES SURG CHEMO SURG/ CHEMO SURG/ CHEMO/RAD NONE ALL OTHERS BASE OF TONGUE 1 0 0 0 0 1 0 PAROTID GLAND 3 2 0 0 0 1 0 OROPHARYNX 1 0 0 0 0 1 0 HYPOPHARYNX 1 0 0 0 0 1 0 OTHER ORAL CAVITY 1 0 0 0 0 1 0 ESOPHAGUS 7 0 1 0 0 6 0 STOMACH 9 5 1 0 0 3 0 SMALL INTESTINE 3 0 0 0 0 3 0 COLON 71 51 1 9 0 10 0 RECTOSIGMOID JUNCTION 4 3 0 0 1 0 0 RECTUM 15 7 0 2 1 5 0 ANUS & ANAL CANAL 3 3 0 0 0 0 0 LIVER & BILE DUCTS 6 0 2 0 0 4 0 GALLBLADDER 5 5 0 0 0 0 0 OTHER BILIARY TRACT 1 0 0 0 0 1 0 PANCREAS 19 0 4 1 0 14 0 OTHER DIGESTIVE ORGANS 2 0 0 0 0 2 0 LARYNX 1 0 0 0 0 1 0 *BRONCHUS & LUNG 85 34 8 2 0 40 1 HEART MEDIASTINUM PLEURA 2 1 0 0 0 1 0 BONES JOINTS & OTHER UNSPECIFIED SITES 2 0 0 0 0 2 0 BLOOD & BONE MARROW 24 0 9 0 0 14 1 SKIN 11 8 0 0 0 3 0 RETROPERITONEUM & PERITONEUM 3 2 0 0 0 1 0 CONNECTIVE SUBCUTANEOUS OTHER SOFT TISSUE 1 0 1 0 0 0 0 BREAST 15 11 0 2 0 1 1 VULVA 3 3 0 0 0 0 0 CERVIX UTERI 3 2 0 1 0 0 0 CORPUS UTERI 22 19 0 1 1 1 0 OVARY 7 5 0 1 0 1 0 PENIS 1 1 0 0 0 0 0 PROSTATE GLAND 7 1 0 0 0 4 2 TESTIS 1 1 0 0 0 0 0 KIDNEY 10 8 0 0 0 2 0 URETER 3 2 0 0 0 1 0 URINARY BLADDER 113 90 1 6 0 13 3 OTHER & UNSPECIFIED URINARY ORGANS 1 1 0 0 0 0 0 MENINGES 1 1 0 0 0 0 0 BRAIN 16 6 1 0 0 9 0 THYROID GLAND 18 17 0 0 0 1 0 OTHER ILL DEFINED SITES 1 0 0 0 0 1 0 LYMPH NODES 28 3 13 0 0 12 0 UNK PRIMARY 29 0 2 0 0 26 1 OVERALL TOTALS 563 292 44 25 3 190 9 * According to SEER statistics 56% of cases with lung cancer are diagnosed after the cancer has already metastasized (distant stage) 10

In accordance with the American College of Surgeons and the Florida Cancer Data Systems (FCDS), each patient is provided with an annual lifetime follow-up service that is essential to evaluate cancer care outcomes. Graph VII. Graph VII. Follow up rate 2010 at DMC 700 665 630 600 500 Nbr of patients 400 300 200 100 35 8.57% 0 DMC Total eligible analytics Total patients expired Total living patients Total lost to follow up 11

Lung Cancer at Delray Medical Center 2010 Lung cancer accounts for more deaths than any other cancer in both men and women. According to the American Cancer Society, an estimated 221,130 new cases of lung cancer are expected in 2011 and an estimated 156,940 deaths will occur, accounting for about 27% of all cancer deaths. Incidence rates in men have significantly decreased. Recent studies show that incidence rates in women have now begun to decline after a long period of increase. Mortality rates have also seen a drop in numbers mainly because of the decrease in smoking rates over the past 50 years. Lung cancers are classified according to the type of cell present in the tumor. There are 2 main types of lung cancer, small cell (14%) and non-small cell (85%), and they are treated differently. Non-small cell carcinoma has 3 subtypes: Adenocarcinoma (40%), Squamous cell carcinoma (25%-30%), and Large cell carcinoma (10%-15%). Other tumors can be found in the lungs too, such as sarcoma, carcinosarcoma, and carcinoid tumors. Cigarette smoking is by far the leading risk factor for lung cancer and accounts for 85% to 90% of lung cancer deaths. The risk increases with quantity and duration of smoking. Discontinuation of smoking at any age lowers the risk of lung cancer and can slowly help damaged lung tissue return to normal. Cigar and pipe smoking also boost risk. Exposure to secondhand smoke either in the work place or at home may cause a higher risk for lung cancer. For instance, non-smoking spouses who live with a smoker have about a 20% to 30% greater risk of developing lung cancer than do spouses of non-smokers. Other risk factors include radon which is a radioactive gas that is invisible, odorless and tasteless, and comes from the breakdown of uranium found in soil and rocks. Asbestos exposure particularly in smokers can greatly increase the risk of developing lung cancer or a type of cancer called mesothelioma which starts in the lining of the lungs. Certain metals, inhaled chemicals or minerals such as arsenic, cadmium and chromium, exposure to radiation, air pollution, history of tuberculosis, family history of lung cancer, and genetic susceptibility may also be contributing risk factors. Lung cancer often takes many years to develop and in most cases without symptoms. Patients often do not develop symptoms until the cancer is at an advanced stage or has metastasized. This is primarily why lung cancer has the highest mortality rate out of all other cancers. If a case is diagnosed at an early stage it is usually discovered incidentally by a chest x-ray. Signs and symptoms depend on the location of the tumor and include persistent cough, chest pain, voice change, coughing up blood or sputum streaked with blood, shortness of breath and recurrent bronchitis and pneumonia. A good screening test to find lung cancer early could save many lives. Unfortunately, studies have not proven these to be useful in reducing the mortality rates in lung cancer. Screenings such as chest x-ray, analysis of cells in sputum, and fiber optic examination of the bronchial passages (bronchoscopy) has shown limited effectiveness in finding lung cancer early enough to improve a person s chance for a cure. The National Lung Screening Trial which is designed to determine the effectiveness of lung cancer screening in high-risk individuals showed 20% fewer lung cancer deaths among current and former heavy smokers who were screened with spiral CT compared to standard chest x-ray. However, these results may not apply to the general population because this study targeted individuals with a history of heavy smoking (at least a pack of cigarettes per day for 30 years). Treatment options vary depending on the histology (non-small cell or small cell), stage of cancer and overall health. They include surgery, chemotherapy, radiation therapy and targeted therapies such as Tarceva and 12

Avastin. Surgery is usually recommended for localized non-small cell carcinoma because it offers the best chances for cure. After surgery, chemotherapy may be added to improve the survival rate of the patient. If the cancer has already spread, radiation therapy in combination with chemotherapy is used. In more advanced stages of non-small cell lung cancer, targeted therapies are often used along with chemotherapy or in cases where chemotherapy is no longer working. Targeted therapies are certain drugs that help prevent the growth of a tumor either by stopping the formation of new blood vessels in a tumor or by blocking a specific receptor that signals cells to grow and divide. For small cell carcinoma the treatment of choice is chemotherapy alone or combined with radiation therapy. The 1-year relative survival for lung cancer increased from 35% in 1975-1979 to 43% in 2003-2006. The 5- year survival for small cell lung cancer (6%) is lower than that for non-small cell (17%). In 2010, a total of 100 analytic lung cancer cases were seen in Delray Medical Center, 79% were non-small cell carcinoma, 7% were small cell carcinoma and 14% were other histologies (Table I.). 13

TABLE I. Lung Cancer at DMC Distribution by Histology Number of Cases Non-Small Cell Carcinoma (79%) Adenocarcinoma nos 41 Bronchiolo-alveolar ca 9 Carcinoma nos 3 Non-small cell ca nos 13 Squamous cell ca nos 13 Small Cell Carcinoma (7%) Small cell ca nos 7 Others (14 %) Carcinoid tumor nos 1 Malignant neoplasm nos 3 Neoroendocrine ca 6 Sarcoma 3 Lymphoma 1 Total 100 The distribution by race graph shows that the majority of lung cancer cases are among the Caucasian population representing 98%. Graph I. Graph I. Lung Cancer at DMC Distribution by Race African American 2% Caucasian 98% 14

There were more females (62) than males (38) diagnosed with lung cancer in 2010 at DMC. Graph II. Graph II. Lung Cancer at DMC Distribution by Gender Female 62 Male 38 0 10 20 30 40 50 60 70 The age of presentation at diagnosis similar between the 70-79 category and the 80-89 category with 38 and 39 cases, respectively. Graph III. Graph III. Lung Cancer at DMC Distribution by Age 50 40 38 39 30 20 10 0 6 13 4 50-59 60-69 70-79 80-89 90 or more Age 15

The predominant topography was in the upper lobe with 46% followed by lower lobe with 30%. Graph IV. Graph IV. Lung Cancer at DMC Topography Distribution Lung nos 18% Overlapping 1% Main Bronchus 1% Low er lobe 30% Middle lobe 4% Upper lobe 46% The tobacco history graph shows the majority of lung cases were among the previous smokers, while the never smoked and current smokers are the same. Graph V. Graph V. Lung Cancer at DMC Tobacco History 100 90 80 70 60 50 40 30 20 10 0 59 15 15 11 Never Current Previous Unknown 16

The leading lung cancer stage group was localized disease with 54%, followed by distant stage with 32%. Table II. Table II. Lung Ca. Distribution by Stage Stage N0. % Local (Stage I) 46 54% Regional (Stage II/III) 11 13 % Distant (Stage IV) 27 32 % Unknown 1 1 % Surgery was the most utilized form of first course treatment for lung cancer with 34%, followed by chemotherapy with 14%. Graph VI. None 18% Graph VI. Lung Cancer at DMC Distribution by First Course Treatment Rad 5% Surg/Rad 1% Chemo 14% Rad/Chemo 2% Follow up data N/A 24% Surg/Chemo 2% Surgery 34% *Note: None represents an aggregate of the following: 2 cases where treatment was not recommended due to the patient having co-morbidities; 2 cases where the patient refused treatment; 7 cases where the patient expired or was referred to hospice; and 2 cases which had palliative treatment to brain mets only. 17

Definitions Analytic: A case that was either initially diagnosed or received all or part of the first course of treatment at the reporting institution. Class 00: First diagnosed at DMC, all treatment (or decision not to treat) elsewhere Class 10: First diagnosed at DMC and part or all of first course treatment (or decision not to treat) at DMC, NOS Class 11: First diagnosed by staff physician and part of first course treatment at DMC Class 12: First diagnosed by staff physician and first course (or a decision not to treat) at DMC Class 13: First diagnosed and part of first course treatment at DMC Class 14: First diagnosed and all first course treatment (or a decision not to treat) at DMC Class 20: First diagnosed elsewhere and all or part of first course treatment at DMC, NOS Class 21: First diagnosed elsewhere and part of treatment at DMC Class 22: First diagnosed elsewhere and all treatment at DMC Non-analytic (includes Class 32): Patient diagnosed and received all first course of treatment at another institution, patients diagnosed at autopsy, and patients diagnosed and treated at the reporting facility before the registry s reference day. Stage: The Tumor Registry collects the staging by using the Tumor, Nodes and Metastasis (TNM) system from the American Joint Committee on Cancer, and Local, Regional or Distant from (SEER) Surveillance, Epidemiology and End Results Program. Stage 0 = In-situ, Stage 1 = Local, Stage 2 = Regional/Direct Extension, Stage 3 = Regional/Nodes Only, Stage 4 = Regional/Direct Extension & Nodes. First course of treatment: Includes all methods of treatments recorded in the treatment plan and administered to the patient before disease progression or recurrence. Successful follow up: Is the percent of dead and living patients that were contacted by the Tumor Registry in the last 12 months. It is required to use registry data for survival analysis. Lost to follow up: Represents the percentage of patients that have not been contacted by the Tumor Registry in the last 15 months. They are also known as delinquent cases. References: - American Cancer Society Cancer Facts & Figures 2011 - Website information: 18

http://www.cancer.gov/cancer_information/, http://www.cancer.org/docroot/home/index, http://seer.cancer.gov/ 19