Sunnybrook/TSRCC Breast Program Strategic Planning Retreat April 23, 2007

Sunnybrook/TSRCC Breast Program

Strategic Planning Retreat

April 23, 2007

2

Breast Cancer: State of the Union

• What has changed?

• What will change ?

3

Breast Cancer in Canada

• Most common malignancy affecting womenin 2002 in Canada 20,500 diagnosed 5,400 died

• Incidence rates have leveled over last 10 years

• Mortality rates have dropped by 25% in last 20 years

4

Preventive Oncology: Key changes in the last 5

years• Increased demand for and utilization of genetic services for assessment of hereditary predisposition

• Increased evidence to support risk reduction interventions in patients with hereditary predisposition to breast cancer

• Chemoprevention of breast cancer ?Research vs. standard of care

• Clarification of Breast Cancer Risk Factors e.g. HRT

• Development of a provincial cancer prevention strategy “Cancer 2020”

5

Preventive Oncology: What can we expect in the next 5 years?

• More complex genetic assessment More genes, more sophisticated testing

• More prevention studies

• More accountability re: provincial targets/CSQI

• More cancer

• NOT more funding

• MRI screening

6

MRI Screening in Canada

• Currently being performed in a few large centres and a few private clinics

• National Hereditary Taskforce Guidelines (Jan/07): Annual mammography should be supplemented by MRI where it is available.

• Ontario PEBC Guideline in final stages. Like ACS but: 25% lifetime risk Includes some patients with LCIS / atypia

• Aim to bring MRI screening under umbrella of OBSP to ensure: Minimum standards are met by all centres Access for all women who might benefit Outcome analysis and CQI

7

Imaging: Key changes in the last 5 years

• Increasing volume US & MRI

• Increasing interventions Core & vacuum assisted biopsies – expense

• Digital mammography

• Choice of residents for teaching

• Clinical research – CAD DMIST ACRIN 6666 Screening Ultrasound MRI high risk screening CEDM & DBT

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Imaging: What can we expect in the next 5 years?

• Screening & increasing diagnostic volume & interventions• OBSP – screening & assessment centre• Conversion to all digital imaging• Timely diagnosis• Research – MRI• Contrast –enhanced digital mammography• Digital Breast Tomosynthesis• CE DBT

9

Surgical Oncology: Key changes in the last 5 years

• More emphasis on “minimally invasive” surgery

• Importance of breast imaging for surgical decision-making

• Importance of multidisciplinary care

• Critical mass of breast surgeons at TSRCC

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Surgical Oncology: What can we expect in the next 5

years?• Increased emphasis on neoadjuvant treatments• Greater reliance on imaging (MRI as standard?)• Greater multidisciplinary care

More resources/patient Better coordination of services/streamlining of appts

needed• Consumer demand for patient-focused services• The challenge of maintaining referral base

Patient navigation Admin support Efficient triage and follow-up services

11

Pathology: Key changes in the last 5 years

screen detected breast lesions Difficult to assess borderline lesions

# of non-palpable breast lesions More volume to process

• Development of new biological markers and their adoption as standard of care Impact on HR, pathology & lab budget

• Pathology has become an integral part of clinical multidisciplinary teams (HR)

• Pathology is a key player in breast cancer research (HR)

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Pathology : What can we expect in the next 5 years?

volume

discovery of new biological markers, both as prognostic and predictive markers

• New molecular / genetic classification

• Molecular finger printing of breast cancer

• Increased use of image analysis for marker assessment

• Identification of stem cell markers

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Radiation Oncology: Key changes in the last 5 years

Infiltrating Ductal Carcinoma

• The Expanding Role of XRT Increasing use of Locoregional XRT

• Improved Techniques of XRT Intensity-Modulated Radiation Therapy less toxicity Boost for women < 50 years old Partial breast radiation (Brachytherapy)

• Reducing the Toxicity of XRT Cardiac toxicity IMRT leads to less scatter

Ductal Carcinoma in Situ• Increasing incidence• Increasing evidence of benefit of XRT• Increasing concerns of under treatment and potential over

treatment

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Radiation Oncology : What can we expect in the next 5 years?

• Early Stage Breast Cancer Partial breast irradiation (external beam/brachytherapy/IORT) Image guidance and Adaptive Radiotherapy Is bolus necessary?

• Locally Advanced Breast Cancer Combined modality therapy Increased intensity of treatment with reduced treatment time Imaging for the evaluation of treatment response (US, PET, MRI)

• DCIS Identify factors predictive of invasive recurrence Improved Risk Stratification

o Lumpectomy /Lumpectomy + XRT / Mastectomy Improve XRT Techniques

o Partial breast irradiationo Role of boost for young women

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Medical Oncology: Key changes in the last 5 years

• Expanded indications for adjuvant chemotherapy Node negative, HER2 positive

• Dose-dense chemo Use of G-CSRF, erythropoetin

• Use of adjuvant taxanes• Increased use of neo-adjuvant therapy• AI’s in adjuvant therapy

Length of adjuvant endocrine therapy• Wide use of bisphosphonates• Use of biologics

Herception – met//adjuvant Lapatinib

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Medical Oncology: What can we expect in the next 5 years?

• New tests for prediction Oncotype DX Other molecular signatures

• Use of biologics in adjuvant therapy

• Use of adjuvant chemotherapy

• Drugs for metastatic disease

• Fewer patients with metastatic disease

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Survivorship: What has changed in the last 5 years?

• Awareness of survivorship issues

• Length of endocrine adjuvant therapy

• More survivors for longer

• Issues of

QOL Exercise, body and weight Other lifestyle issues

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Survivorship : What will change in the next 5 years?

• Extended endocrine adjuvant therapy

• Focus on lifestyle issues

• Biologics and their long term effects

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Palliative Care: Key changes in the last 5 years

• Expanding role in the care of patients prior to end-of-life

• Clinical expertise in the management of symptoms associated with breast cancer: lymphedema, brachial plexopathy, complex neuropathic/bony mets pain syndromes

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Palliative Care: What can we expect in the next 5 years?

• As the research base within the field of palliative medicine expands, greater body of evidence for targeted and individualized pain and symptom management interventions

• Expanding role for interventional pain management procedures: nerve blocks

• Ongoing source of care and support for patients with disease progression

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Care Delivery Models: Key changes in the last 5 years

• Screening Programs (OBSP)• Diagnostic Assessment Units • Multidisciplinary Programs• Survivorship Programs

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Diagnostic Assessment Units

• Completing diagnostic evaluation in a streamlined, comprehensive and timely manner

• Principles Patient-focused Multidisciplinary Timely

• Components Triage mechanism Breast imaging: mammography, US, biopsy, MRI Clinical assessment Patient Navigator

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Diagnostic Assessment Unit : What might it look like?

• Triage referrals Imaging

o Screening or diagnostic Clinic

o Surgical or nonsurgical

• Streamlined diagnostic imaging All diagnostic studies (except MRI) same day MRI and MRI-generated FU studies same day

• Rapid turnaround of pathology• Prompt clinic appt after diagnostic evaluation• Patient navigation/nursing support

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Breast cancer : Summary of Key changes in

the last 5 years • Improved and expanded screening and early diagnosis• Reduced mortality rates• Reduced or stable incidence rates• Increased use of imaging• Use of sentinel node• More breast conserving surgery• New radiation approaches• Improved adjuvant endocrine therapy• New adjuvant chemotherapy• Biologics

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Breast Cancer : Key changes in the next 5 years

• New approaches to surgery

Image-guidance• New approaches to radiation

Image-guidance• New approaches to systemic therapy

Especially biologics• Lifestyle approaches for survivors• More survivors for longer

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What Do Women Want?

In-depth interviews with:

• Health care providers• Former patients• Informal caregivers• Telephone survey of 800

women without cancer• Cancer professionals

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Executive SummaryThe Problem

• Lack of coordination of care

• Gaps in communication between health care providers

• Lack of psycho-social support with the shock of the diagnosis

• Lack of information: Feeling “numb and dumb” at time of critical treatment decision-making

• Provider knowledge “Many participants expressed

disappointment with the breast cancer knowledge of their primary care providers”

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Executive SummaryThe Problem

• Lack of coordination of care

• Gaps in communication between health care providers

• Lack of psycho-social support with the shock of the diagnosis

• Lack of information: Feeling “numb and dumb” at time of critical treatment decision-making

• Provider knowledge “Many participants expressed

disappointment with the breast cancer knowledge of their primary care providers”

The Potential Solution

Navigator ?

Multidisciplinary care ?

Increased Psychosocial support

Educational websites? Brochures? DVDs?

Well follow-up clinics?

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What Could Make Treatment for Breast Cancer a “Wonderful

Experience?”• Informed Participation

• Emotional Support

• Timeliness

Breast Cancer at TSRCC/Sunnybrook

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Breast Cancer at TSRCC• One of 2 largest breast programs in Canada• One of 6 or 8 largest breast programs in North America• Primary nursing model• Multidisciplinary care• Interdisciplinary care• Strong emphasis on research/teaching

• Volumes Surgery volumes

Radiation volumes

Medical Oncology volumes

See handout in package for breast activity at TSRCC

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Breast Site Group at TSRCC• 17 Medical Oncologists • 16 Radiation Oncologists• 4 Surgeons• 3 (4) Specialist pathologists • 2 (3) Specialist diagnostic imagers• 15 RNs • Social workers• Dietitians • Pharmacists • Physicists• Radiation therapists• Genetic counselors

Accomplishments

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Honors and Awards

• Prominent Role in NCIC/CTG – Breast Group• Prominent Role in OCOG Breast Group• Fellowship Program

Campbell Endowed Fellowship Industry Fellowships CAMO Fellows CBCF Fellows

• CFI Awards 11.2 x 106$ for Breast Centre

• Breast Centre – 27 million dollars• As a primary fundraising target SHSC

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Honours and Awards (cont’d)

• Grants: o Dr. Eileen Rakovitch – largest CBCRA grant 2007, 5

yearso Dr. Arun Seth

– CBCRA 2005-2010 Metastatic “Breast Cancer Genome Anatomy” $ 610,000

– CBCRA (Grant Core Component) 2005-2010 “New Approaches to Metastatic Disease in Breast Cancer (METS)” $ 969,067

– NIH, USA 2007-2012 The BCA2 Ubiquitin E3 Ligase as a Target in Breast Cancer $1,759,000 USD

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Honours and Awards (cont’d)

• Grants: o Dr. Greg Czarnota

– 2 OICR grants ~$300,000– CBCF $428, 000

o Drs. Yaffe/Plewes – Terry Fox Granto Dr. Claire Holloway and others

– OCRN grant ~ $300,000

• Plenary Session at ASTRO – Dr. Jean-Philippe Pignol

• O.H. Warwick Award - Dr. Kathleen I. Pritchard, 2005

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Landmark Papers• Warner E. et al. Surveillance of BRCA1 and BRCA2 Mutation

Carriers With Magnetic Resonance Imaging, Ultrasound, Mammography, and Clinical Breast Examination. JAMA. 2004; 292:1317-1325

• Yaffe, M. et al. Diagnostic Performance of Digital versus Film Mammography for Breast-Cancer Screening. New England Journal of Medicine, Volume 353:1773-1783 October 27, 2005 Number 17

• Pritchard, K.I. et al. HER2 and Responsiveness of Breast Cancer to Adjuvant Chemotherapy. New England Journal of Medicine, Volume 354: 2103-11, May 18, 2006 Number 26

• Seth, A.K. et al. A Novel RING-Type Ubiquitin Ligase Breast Cancer-Associated Gene 2 Correlates with Outcome in Invasive Breast Cancer. American Association for Cancer Research.

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Prevention: Accomplishments

• Comprehensive assessment of genetic and cancer risk

• Accrual to chemoprevention studies• Follow-up of high risk women• Participation in collaborative

research• Education/training• Regional role

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Surgery:Accomplishments

• Establishment of an academic program in breast surgery Fellowship training program Critical mass of academic surgeons

o Standardized multi- and interdisciplinary care Integrated research program

o Multidisciplinaryo Partnerships with U of T, ICES, CCO

Surgical representation at provincial, national organizations• Grants

Imaging and histopathology correlation after neo-adjuvant chemotherapy (CBCF)

Radioimmunoguided surgery (OCRN) Evaluating the quality of sentinel lymph node biopsy

quality in Ontario (CBCF) Patterns of breast cancer surgery in Ontario (CCO)

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Pathology : Accomplishments

• Sign-out of breast cases by dedicated specialized pathologists

• Adoption of synoptic reporting

• Testing for ER/PR and Her2/neu on all patients at the time of diagnosis

• Improving TAT. In general, only 10% of cases are >10 days for the whole department (all specimen types)

• Leader for setting provincial and national Her2 testing guidelines and QA program

• Established TMA facility

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Academic achievements:a) Grantsb) CME activitiesc) Tumour Boardsd) Regular clinicopathological rounds weekly

e) Member of expert panel and publication of CAP/ASCO guidelines (Wolff AC, Hammond EH, Schwartz JN. Guideline Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer. J Clin Oncol 2007;25(1):1-28.)f) Tumour Banking initiative (old & new)

Pathology : Accomplishments

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Radiation Oncology: Accomplishments

• Prevention / Screening Population-based assessments of screening

• Treatment Development of a Permanent Breast Seed implant PI of randomized clinical trial on Breast IMRT

o Plenary Session at ASTRO Development of international bone metastases module to

accompany the EORTC QLQ-C30 for patients with bone metastases.

PI on International RCT of Single versus Multiple Fractions for Re-Irradiation of Painful Bony Metastases – NCIC SC 20

Chemoradiation for LABC Novel imaging of LABC to determine response to treatment

• Outcomes Establishment of population-based provincial cohort of DCIS, LCIS

(Pathology) Population-based assessment of cardiac toxicity following XRT for

breast cancer

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Medical Oncology : Accomplishments• Strong contribution to new international standards for adjuvant endocrine,

biologic and chemotherapy via NCIC CTG (MA.5, MA.17, MA.17R, MA.21, MA.27)

• Strong phase II program: NCIC CTG PMH Consortium

• Strong Correlation phase I-IV programs MA.22 MA.29

• Chemo radiation• LABC programs• BLISS programs

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Specialty Clinical Components

• Primary Nursing Model• LABC• Brachytherapy• Lymphedema clinic• Breast prosthesis• BLISS

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LABC ProgramMission• To provide consistent, high quality, multidisciplinary care in

a patient-centered or needs-led format.

Objectives• Increase understanding of long-term clinical outcomes.• Design program of excellence.• Continue national preceptorship program for health care professionals.

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Ongoing Clinical Trials

Imaging:

MRI Study (Wright)

MRI Technique (Czarnota)

Spectroscopy (Czarnota)

Psychosocial:

Risk Perception

Delayed Presentation

Male Partner’s Role

(Fergus/Fitzgerald)

Neoadjuvant Therapy:

MA.22 (Trudeau)

ATSEA (Clemons/Holloway/Verma)

Chemorads (Spayne/Holloway)

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LABC: The Future

• Maintain high quality, multidisciplinary care for our patients

• Re-institute RN lead program• Improve public awareness• Maintain LABC database • Improve outcomes for women with LABC

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Breast Brachytherapy

• 20 ~ 30% of patients with Early Stage Breast Cancer are potentially eligible

• Unique to TSRCC in the GTA

• Includes 2 types of procedures: Permanent Breast Seed Implant High Dose Rate (HDR)

brachytherapy

49

• Developed at Sunnybrook Not (yet) offered anywhere else Huge PR impact Visitors from USA and Europe

• Main advantages : 1 hour procedure Minimal toxicity Minimal exposure of radiation to

normal tissues

• Current Status Phase I/II Trial complete (65 patients) Presented at international meetings

Permanent Breast Seed Implant

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HDR Brachytherapy• Different technique Insertion of multiple catheters Treatment is delivered bid x 5

days

• Advantages: can be used in cases where seeds not feasible

Large seroma Large volumes

• Great potential for Image Guided Brachytherapy research

• StatusNSABP B-39

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The Future of Breast Brachytherapya. Identify SPACEb. Identify funding for seedsc. Create a Database d. Establish a Training Programe. Establish an Image-guided therapy Program

CT planningCT planning

Is the localization correct?

Is the localization correct?

Is the implantation homogeneous?

Is the implantation homogeneous?

OGIPSOGIPSResonantResonant

Is there any geographical miss?

Is there any geographical miss?

C-arm CTC-arm CT

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Lymphedema Clinic

• 1990 N.P. 2 per week,2007 6 N.P.per wk.• Growth 2006, 300 N.P. F.U 700 from all sites• Now 2 Nurses• Clinics expanded to 2 ½ days per week

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Lymphedema Highlights

• Patient information booklet in progress• Education booklet in progress• Visiting Therapists• Palliative Care Physicians rotate through clinic• Inpatient consults• XRT Student Research• Staff inservice and staff orientation• Delta Study participation

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Breast Prosthesis

• Craniofacial Prosthetic Unit • Trial currently underway comparing artistic

custom breast prostheses against current standard prostheses

• Assessing patient demand, patient preference, business model, and technical methods

• Early results extremely encouraging• Objective is to integrate custom breast

prostheses into breast site care path

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BLISS: A Program for Young Women With Breast Cancer

Breast cancer before 40Life after cancerInnovative treatmentsScientific researchSupport for women and their families

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BLISS Executive Summary

• 5% of breast cancers occur in women < age 40 at diagnosis (10% of TSRCC patients)

• Disproportionately represent ‘breast cancer burden’ of excess morbidity, mortality, and loss to society.

• Women have special clinical needs which are currently not being met

• Large research gaps exist• CLINICAL AND RESEARCH CHALLENGE

BLISS• Interdisciplinary treatment and research program• Opportunity to:

Create a new model of care Improve outcomes of all young women with breast cancer

Research

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External funding has more than tripled…History of Funding at Sunnybrook Research Institute

102.599.0

95.9

91.0

83.081.079.0

76.2

19.518.016.914.8

4.65.36.06.7

0

20

40

60

80

100

120

98 99 00 01 02 03 04 05 06 07 08

Fiscal Year

$ M

illio

n Total ExpendituresTotal External FundingTotal OperatingSHSC Operating Contribution

59

60

Our Research Directions• Improved detection

Developments in breast MRI, tomosynthesis Population-based assessments of screening

• More accurate diagnosis 3D pathology, high field MRI

• Efficient and accurate localization for biopsy/therapy MRI, US

• More precise, less invasive surgical treatment Image-guided surgical intervention (Intraoperative US, specialized

surgical instruments)

• New radiation techniques Brachytherapy Image-guided radiation therapy

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Our Research Directions

• Phase II/III trials With major correlational components

• Monitoring response to therapy High and mid freq ultrasound

• Patient-specific treatment Molecular profiling, correlative studies(tumour/tissue/image

data warehouse), and mid/high frequency US and MRI• Better understanding of disease processes

High field MRI, molecular pathology, 3D pathology Identifying tumour signatures leads to improved detection,

diagnostic and therapeutic techniques, preventive measures

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Our Research Directions

• Palliative research• Psychosocial research

Psychosocial and Behavioral Research Unit (790 Bay Street) Community Research Initiative (survivorship issues, health

disparities, participatory research expertise) Ontario Breast Cancer Information Exchange Partnership (needs

assessment, dissemination expertise)• Outcomes Research

Ongoing independent research projects evaluating breast cancer outcomes:

o DCIS, LABC, young women, BRCA, Henrietta Banting Database

No formal organization or co-ordination of projects or resources CFI funded data server for patient data and imaging (hardware

in H wing)

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Clinical Outcomes Unit: Future• COU planning group (ER, LP, MLQ) meeting bimonthly to

shape the initial vision of the COU

• Collaborate with existing provincial resources to determine the elements of the TSRCC Outcomes Unit

• Develop a comprehensive provincial population-based patient database

• Acquisition of complete data on treatment and outcomes

• Develop research priorities

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Breast Cancer Research at SHSC

SurvivorImproving the QOL of women with Breast Cancer

IncreasedConvenienc

e

Lower morbidity

Greater support

Higher cure rates

65

Breast Cancer Research at TSRCC

SurvivorImproving the QOL of women with Breast Cancer

IncreasedConvenienc

e

Lower morbidity

Greater support

Higher cure rates

IMRT

Breast Brachytherapy

Scatter Study

Cardiac Toxicity

DCIS / LCIS

Image-guidance

Bolus StudyPalliation of Bone Mets

Education / Preferences

Outcomes

66

Breast Cancer Research at TSRCC

SurvivorImproving the QOL of women with Breast Cancer

IncreasedConvenienc

e

Lower morbidity

Greater support

Higher cure rates

IMRT

Breast Brachytherapy

Scatter Study

Cardiac Toxicity

DCIS / LCIS

Image-guidance

Bolus StudyPalliation of Bone Mets

Education / Preferences

Hot Flash Therapy Trials

Phase IIStudies of Cognitive

Change on Chemotherapy

Adjuvant ChemotherapyEndocrine, Biologics

Outcomes

67

Breast Cancer Research at TSRCC

SurvivorImproving the QOL of women with Breast Cancer

IncreasedConvenienc

e

Lower morbidity

Greater support

Higher cure rates

IMRT

Breast Brachytherapy

Scatter Study

Cardiac Toxicity

DCIS / LCIS

Chemoradiation

Image-guidance

Bolus Study

LABC clinic

BLISS clinic

Palliation of Bone Mets

Education / Preferences

Hot Flash Therapy Trials

Phase IIStudies of Cognitive

Change on Chemotherapy

Adjuvant ChemotherapyEndocrine, Biologics

SurvivorshipProgram

Outcomes

68

Breast Cancer Research at TSRCC

SurvivorImproving the QOL of women with Breast Cancer

IncreasedConvenienc

e

Lower morbidity

Greater support

Higher cure rates

IMRT

Breast Brachytherapy

Scatter Study

Cardiac Toxicity

DCIS / LCIS

Chemoradiation

Image-guidance

Bolus Study

LABC clinic

BLISS clinic

Palliation of Bone Mets

Education / Preferences

Hot Flash Therapy Trials

Phase IIStudies of Cognitive

Change on Chemotherapy

Adjuvant ChemotherapyEndocrine, Biologics

SurvivorshipProgram

Outcomes

Experimental OR

69

Breast Cancer Research at TSRCC

SurvivorImproving the QOL of women with Breast Cancer

IncreasedConvenienc

e

Lower morbidity

Greater support

Higher cure rates

IMRT

Breast Brachytherapy

Scatter Study

Cardiac Toxicity

DCIS / LCIS

Chemoradiation

Image-guidance

Bolus Study

LABC clinic

BLISS clinic

Palliation of Bone Mets

Education / Preferences

Hot Flash Therapy Trials

Phase IIStudies of Cognitive

Change on Chemotherapy

Adjuvant ChemotherapyEndocrine, Biologics

SurvivorshipProgram

Outcomes

Image-guided surgery

Education

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Health Care Education Activities

• Undergraduate• Postgraduate

Residents Fellows

• Other health care professionals Oncologists

o Regional Cancer Centers Family Physicians Nurses and Pharmacists Allied health care workers

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Health Care Education Activities

• Current Key Education Activities Local

o Breast Cancer Roundso Breast Cancer Visiting Professorshipo Toronto Breast Cancer Guidelineso Fellowship Program

• Current Key Education Activities National and International

o Breast Cancer Fellowship Programo www.oncologyeducation.cao Toronto Breast Cancer Symposia

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Patient Education

• Patient Education Program – strategic priority for TSRCC

• Providing Patients with the right information, at the right time, in the right way, by the right people

• Breast Site including Breast Centre has identified commitment to patient education throughout draft functional program

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Patient Education Initiatives

• Breast Cancer Patient Portal• Breast site patient education package

Development of Internal Breast Resources (lumpectomy, mastectomy, lymphedema booklet)

• Patient Education and Learning Resource Centre (PEARL)

• Patient Education Satellite Site (Breast Centre)

Ontario Breast Screening Program

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GTA OBSP Growth Pattern

0

20

40

60

80

100

120

140

160

180

2004/05 2005/06 2006/07 2007/08 Projected

Fiscal Year

Nu

mb

er

Number of Affiliates Sites Screening Numbers x 1,000

77

GTA OBSP Growth Pattern

0100200300400500600700800

2004

/05

2005

/06

2006

/07

2007

/08

Proje

cte

d

Targ

et

Fiscal Year

Num

ber

Number of Affiliate SitesScreening Numbers x 1,000

78

Toronto Central OBSP Growth Pattern

05

101520253035

2004/05 2005/06 2006/07 2007/08Projected

Fiscal Year

Num

ber

Number of Affiliate SitesScreening Numbers x 1,000

79

Toronto Central OBSP Growth Pattern

020406080

100120140

2004

/05

2005

/06

2006

/07

2007

/08

Proje

cte

d

Targ

et

Fiscal Year

Num

ber

Number of Affiliate SitesScreening Numbers x 1,000

Breast Activity at TSRCC

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Data for March is projected, only data for February 2007 is currently available. Data for Preventative Oncology is under review.

Number of New Breast Cases Per Year

1,603 1,6371,504

1,607

511645 627 578

396 457549

457607

717805

694

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2003/04 2004/05 2005/06 2006/07

Fiscal Year (April to March)

Ca

se

s

New Radiation Cases (C1R) New Systemic Cases (C1S)

New Surgical Cases (C1U) New Preventative Oncology Cases (V1)

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The number of new cases were compared to the pervious year’s cases to determine the percent change. All new cases to all areas were included and as a result, an individual patient may be counted more than once. Data for March is projected,

only data for February 2007 is currently available. Data for Preventative Oncology is under review.

Percent Change in New Breast Cases

-30

-20

-10

0

10

20

30

2004/05 2005/06 2006/07

Fiscal year (April to March)

Pe

rce

nt

Ch

an

ge

New Radiation Cases (C1R) New Systemic Cases (C1S)

New Surgical Cases (C1U) New Preventative Oncology Cases (V1)

New Preventative Oncology Cases (V1)

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Percent Change in Total New Breast Cases

10.88

0.84

-10.59

-15

-10

-5

0

5

10

15

2004/05 2005/06 2006/07

Fiscal year (April to March)

Pe

rce

nt

Ch

an

ge

The number of new cases were compared to the pervious year’s cases to determine the percent change. All new cases to all areas were included and as a result, an individual patient may be counted more than once. Data for March is projected,

only data for February 2007 is currently available. Data for Preventative Oncology is under review.

84

Data for March is projected, only data for February 2007 is currently available. Data from Preventative Oncology will be provided at a later date.

Distribution of New Breast Cases

48%

17%

13%

22%

New Radiation Cases (C1R) New Systemic Cases (C1S)

New Surgical Cases (C1U) New Preventative Oncology Cases (V1)