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Executive Medical Staff: Report of the Cancer Committee
November 12, 2013
Urjeet A. Patel, MD FACS
Stroger Hospital of Cook County
Chairman
Division of Otolaryngology
Head/Neck Surgery
Chairman
Cancer Committee
Cancer Committee
Urjeet A. Patel, MD Chairman
Gianlucca Lazarro, MD Cancer Liaison MD
Patrick Dunne, MD Radiology
Thomas Lad, MD Medical Oncology
Ozuru Ukoha, MD Thoracic Surgery
Lillian Hussein, MD Medical Oncology
Elizabeth Marcus, MD Breast Surgery
Marin Sekosan, MD Pathology
Karen Ferrer, MD Pathology
Andrew Kulic, MD Psychiatry
Harish Thakrar, MD Rad. Oncology
Patricia Vidal, MD Urology
Donald Trepashko, MD Nuclear Medicine
Gloria Hart, CTR Tumor Registry
Catherine Strong, RN Nursing
Catherine Deamant, MD Palliative Care
Krishna Das, MD Quality Assurance
Hazel Feliciano Social Work
Ernestine Daniels Pastoral Care
Brienda Averhart Comm.Rep.
Edgardo Yordan, MD Gyne. Oncology
Erika Radeke CCOP Clin.Trials
Cancer Committee
• Regulatory Issues
• Cancer Stats for this year
• Programmatic studies and endeavors
• Future Considerations
Regulatory Issues
3-year cycle of accreditation by the Commission on Cancer: American College of Surgeons July 16, 2013: one day site visit Reviewed as an Academic Comprehensive Cancer Program Participation from Drs. Fegan and Shannon, and the Cancer Committee
Accreditation
Standard 1.9: Clinical trial accrual
Standard 1.11: Cancer Registrar Education
Standard 2.2: Nursing Care: 25% with oncology certification
Performance Report: Areas of Commendation
Accredited for 3 years, with contingency
Will require corrective action moving forward to address any outstanding deficiencies
Re-Accreditation Action Plan
Tumor Board Presentations
Tumor Board Presentation 2007 2008 2009 2010 2011 2012
Breast 6 2 2 2 2 1
Lung 5 4 3 3 5 4
Head/Neck Esophageal 7 5 9 5 11 5
Upper GI 16 10 16 21 25 25
Lower GI 8 9 7 5 3 4
Hepatobillary 3 9 8 2 6 3
GU 16 19 13 9 3 4
Gyne 4 2 6 3 4 9
Soft Tissue 17 6 32 41 23 28
Leukemia/Lymphoma 14 11 1 8 1 2
Brain 14 12 3 2 2 2
Other 6 4 5 3 8 9
TOTAL 116 93 105 104 92 96
Multidisciplinary Tumor Conferences
Breast Conference Thursday morning 8am
Thoracic Oncology Conference Monday morning 7:30 am
Head/Neck Cancer Conference Tuesday at 3pm
Gyn/Onc Conference Wednesday 8:30 am
Gastrointestinal Oncology Conference 2nd and 4th Thursday 2pm of the month.
Leukemia/Lymphoma Conference Wednesday 12-1pm and Friday 1-2 pm.
Soft Tissue and Melanoma Conference Tuesday at noon
Neuroendocrine Tumor Conference Quarterly meeting
Endocrine: Thyroid Monthly 3rd Thursday
GU Monthly 3rd Fri
JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY 2012 CANCER STATISTICS
In 2012, John H. Stroger, Jr. Hospital of Cook County (JHSH) recorded 1,677 with 1,612 analytic cancer patients, showing a slight
increase of over 1,600 cases within the last 10 years. This increasing trend in the number of analytic patients is reflected in (see graph, S9)
of the annual report The patient population treated at JHSH remains predominantly Black/African American 52% (see graph, S3), with
(780) 48% female and 832) 52% male (see graph, S4).
The patients’ overall age range distribution was from 8 to 90+ years, with the peak age range between 50 to 69 years for both males and
females, and a mean age of 56 years.
The most common malignancies treated at JHSH include breast, prostate, lung, and colon & rectum cases. They are among the top five
cancer sites and rank closely within the overall national percentage average for these cancer sites (see graph, S5).
The vast majority of new cancer patients were diagnosed and/or treated at JHSH and are classified as analytic cases. A small number of
patients were diagnosed and treated elsewhere and are classified as non-analytic cases (see graph, S7). The overwhelming majority of new
analytic cancer patients were categorized as Class 10–14, patients in that they were both diagnosed and treated exclusively at JHSH (see
graph, S7).
A large number of JHSH patients are diagnosed with late-stage disease (see graph, S8).
Multimodal therapeutic regimens were often utilized to treat advanced stage cancer patients that presented to JHSH. The most commonly
modalities used in the treatment of cancer patients includes (Chemotherapy, Radiation Therapy, and Surgery), in various combinations [see
graph, S8].
In spite of the fact that more JHSH cancer patients present with relatively advanced disease than in the general population (nationwide)
94% of these patients were alive at the time of this report (see graph, S10), and the vast majority of cancer patients seen at JHSH lived in
Cook County.
Black52%
White
37%
Asian9%
Unknown
2%
John H. Stroger, Jr. Hospital of Cook County
2013 Cancer Committee Annual Report 2012 Analytic Race Distribution
52%
Female, 48%
John H. Stroger, Jr. Hospital of Cook County2012 Analytic Gender Distribution
Male Female
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
Lung Breast Prostate Colon & Rectum Hematopoietic & reticuloendo System
12.66%
11.60% 11.60%
9.37%
5.83%
13.98% 13.82%
14.61%
9.17%
7.39%
13.80% 13.84%
14.75%
8.75%
7.16%
Per
cen
tage
%
Sites
John H. Stroger, Jr. Hospital 2013 Cancer Committee Annual Report Top Five Cancer Sites Comparison Graph
JHSH IL US
Source: ACS Cancer Facts & Figures 2012,
estimated New Cancer Cases for Illinois and United
States
STROGER HOSPITAL OF COOK COUNTY
Summary By Body System and Sex Report
All Other Sites - 202 (24%) All Other Sites - 238 (31%)
Images reprinted by the permission of the American Cancer Society, Inc. from www.cancer.org . All rights reserved.
Non-Hodgkin Lymphoma - 29 (3%) Non-Hodgkin Lymphoma - 18 (2%)
Melanoma of the Skin - 10 (1%) Melanoma of the Skin - 5 (1%)
Leukemia - 27 (3%) Leukemia - 21 (3%)
Urinary Bladder - 29 (3%) Ovary - 29 (4%)
Colon & Rectum - 96 (12%) Uterine Corpus - 74 (9%)
Prostate - 187 (22%) Colon & Rectum - 77 (10%)
Thyroid - 38 (5%)
Lung & Bronchus - 79 (10%)Lung & Bronchus - 125 (15%)
Breast - 184 (24%)
Pancreas - 26 (3%)
Kidney & Renal Pelvis - 34 (4%) Kidney & Renal Pelvis - 17 (2%)
Males Females
Oral Cavity & Pharynx - 67 (8%)
Class 00 1%
Class 10-14 80%
Class 20-22 15%
Class 30-32 4%
John H. Stroger, Jr. Hospital of Cook County 2012 Total Class of Case Percentage Distribution
Stage 03%
Stage I25%
Stage II17%
Stage III16%
Stage IV25%
Stage 889%
Unk7%
John H. Stroger, Jr. Hospital of Cook County 2013 Cancer Committee Annual Report
Analytic Best CS/AJCC Stage Distribution
Stage 0 Stage I Stage II Stage III Stage IV Stage 88 Unk
Surgery 31%
Chemotherapy 29%
Radiation Therapy 25%
Hormone 3%
Other 3%
No treatment 9%
2012 1st Course Treatment Modalities Distribution
Alive 94%
Dead 6%
John H. Stroger, Jr. Hospital of Cook County 2013 Cancer Committee Annual Report
Analytic Cases Vital Distribution
Alive Dead
THE COOK COUNTY HOSPITAL CANCER REGISTRY
The Cancer Registry is utilized to collect and report various relevant parameters
regarding cancer patients such as race, age, and type of cancer. Such data
collection gives important insight to evaluate.
• Cancer incidence trends
• Adequacy of work-up
• Therapeutic results
• Adequacy of follow-up
The Cancer Registry supports the hospital cancer program as well as affiliated
community health projects, including cancer screening and cancer
education.
Cancer data once collected is electronically transmitted to both the State of
Illinois Cancer Registry and the National Cancer Data Base.
The Cancer Registry standards are monitored and kept in line with American
College of Surgeon Commission on Cancer guidelines.
CANCER REGISTRY AND CLERICAL STAFF
Gloria Hart, CTR – Supervisor
Constance Johns, RHIA,CTR – Supervisor hired September 2013
Denise Henry – Clerk V
Carolyn Vazquez – Clerk V
Virginia Williams – Clerk V
2012 SUMMARY OF STUDY PARTECIPATION
REPORTING OF REGISTRY DATA
Illinois State Cancer Registry……………………………..Annual Data Transmission
(No studies offered)
American College of Surgeons/………………………….. Annual Data Transmission
National Cancer Data Base (No studies offered)
Hospital Cancer Committee Internal Studies:
•Cancer Committee Chairman – Bureau wide Cancer Program Presentation
•Cook County Bureau Administration – Breast, Head/Neck, & Prostrate Study
•Hematology/ Oncology – CML Study
•Medical Oncology – 2012 Colon-Rectal Cancer Study
•Medical Oncology – 2012 Lymphomas HL & NHL Study
•Medical Oncology – Ovarian Cancer Study
•Medical Oncology – QA Report
•Medical Oncology – 2012 Lung Cancer Study
•Research & Education – 2010 Analytic Primary Site & Stage Distribution
•Research & Education – 2011 Analytic Primary Site & Stage Distribution
•Research & Education – 2012 Cancer Registry Follow-up Requests
•Surgical Oncology - 2012 Kidney Cancer Study
•Surgical Oncology – 2012 NCDB (CP3R) Breast, Colon & Rectal Comparison
Clinical Trials
Minority-Based Community Clinical Oncology Program (MB-CCOP) NCI funded grant Scope: enrollment of patients on NCI-sponsored cancer treatment and cancer control studies – PI: Tom Lad; Associate PI: Urjeet Patel – >$3 million for 5 years
In place at Stroger for 10+ years; Changing funding mechanism; New Application came out this week; <2 months Will require timely cooperation from senior administration, Dept. chairs
SHCC MB-CCOP Personnel
Personnel: Role 100% external Funding Erika Radeke Administrator NCI Marisol Soto Secretary NCI Nicole Acosta Regulatory Affairs NCI Wendy Rogowski PAC Head CRA NCI Vanessa Barrera CRA NCI Karen Carter CRA NCI Barbara Lucasczcyk CRA NCI Almae Uy CRA NCI Tomas Mackevicius Information Officer NCI Deneisha Brown Contract CRA NCI Namrata Das Batra Contract CRA NCI Ariel Chavez PAC CRA Rush Agreement Barbara Cleveland RN RN Rush Agreement (1/3) Marciana Bowen RN RN Rush Agreement Augustine Haidau Heme/Onc Div. funds Khosrow Zarei Heme/Onc Div. funds
SHCC MB-CCOP Accrual
2007 2008 2009 2010 2011 2012 2013
ACOSOG 1
BCIRG
CALGB 4 8 5 28 64 41 3
CCCWFU 3 9 7
ECOG 79 39 21 43 14 5 3
GOG 3 13 11 3
IBCSG
MOFFITT/SCUFS 2 7 17 6 1
NCCTG 4 2
NCIC 10 1
NSABP 26 12 6 14 4 14 7
RTOG 9 17 20 33 11 20 5
SWOG 2 2 2 14 4
UMBCCOP
Non-NCI 34 36 9 4 0 30 22
Total 154 125 80 130 115 154 56
QI/QA Projects
Considering projects to track positive pathology results: global project with Dr. Das
Palliative care: project underway to improve quality of deaths of patients under palliative care with use of comfort care order set
Considering goal of improving oral care for head/neck cancer patients (pre-xrt treatment, dentures, etc)
Establish Cancer Survivorship plan, and psychosocial assessments of cancer patients
Site-Specific analysis of Pancreatic Cancer; Dr. Gupta
Annual Report will be posted online
Conclusions
Stroger Hospital/CCHHS is providing state-of-the-art comprehensive cancer care, though we are questionably belows standards set by the Commission on Cancer
High-quality care delivered
Deficiencies to be resolved, though more stringent requirements pending
Additional resources/IT support will be required to comply to increasingly stringent program requirements:
Tumor Registry: currently understaffed; further training/staffing required
Pathology: must better support site-specific cancer conferences
New standards: Survivorship planning, psychosocial screening, community-needs-based assessment of screening programs
Final analysis for 2013 work-product pending
Cancer Committee Annual Review 2013
Cancer site review – Pancreas
Shweta Gupta, MD Attending Physician
Div of Hematology-Oncology John H Stroger Jr. Hospital of Cook County
Risk Factors RISK FACTOR RELATIVE RISK
Smoking 2 – 5
DM 2
High BMI 2
Chronic Pancreatitis 13 – 18
Hereditary Pancreatitis 10 – 53
FAMMM syndrome 22
HNPCC 8
Peutz-Jeghers 13 – 30
Familial adnomatous polyposis 4 – 5
Li-Fraumeni ?
BRCA2 3 – 5
Clinical Presentation
• Jaundice (50% of patients)
• Weight loss
• Anorexia
• Bloating
• Steatorrhea or diarrhea
• Abdominal pain or back pain or both
Diagnosis
• Abdominal Ultrasound
• CT Abdomen
• Biopsy (Percutaneous or Endoscopic)
• Serum CA 19-9
– Elevated in 80% of pancreatic ca cases
– Low specificity
– If elevated can be used to follow during therapy
Staging
Treatment
• Localized: Radical pancreatic resection +/- post-op radiation and/or chemotherapy
(5-FU or gemcitabine)
• Locally Advanced: chemotherapy +/-radiation or clinical trial
• Metastatic Disease:
chemotherapy (gemcitabine)
• 20% of potentially resectable disease would be unresectable at surgery
• Surgical morbidity and mortality is inversely proportional to experience of the surgical center
– Not related to postoperative care
Treatment
• At the time of diagnosis: – 15-20% of pts have localized and resectable tumors – 40-45% have localized tumors that are unresectable
(generally due to vascular invasion) – 40-45% have distant metastases
• Contraindications to surgical resection: – Mets to liver, peritoneum, omentum, or any extra-
abdominal site – Encasement of celiac axis, hepatic artery or SMA – Involvement of splenoportal confluence – Involvement of bowel mesentary – Involvement of SMV or portal vein
• Positive surgical margin = very poor prog
AUTHOR N Margin status Median survival
Sohn 184 R1/R2 12
Neoptolemos 101 R1 11
Nishimura 70 R1/R2 6
Millikan 22 R1 8
Richter 72 R1/R2 12
Kuhlman 80 R1/R2 16
Takai 42 R1/R2 8
• Surgically resected patients remain at risk of local failure or metastatic disease
• 80% recur
• Perineural invasion is an important mediating factor
NEOADJUVANT
Author N Regimen Resection rate
% R1 Median survival
Evans 1992 28 5FU + XRT 50.4 Gy 61 ? 18
Pisters 1998 35 5FU + XRT 30 Gy
57 10 25
Pisters 2002 37 Taxol + XRT 30 Gy
54 32 19
Evans 2008 86 Gem + XRT 30 Gy 75 12 34
Vardhachar2008
90 Cis/Gem then Gem + XRT 30 Gy
58 4 31
• Not the standard of care
• Should be considered for borderline resectable disease
– Remember of all patients deemed resectable and taken for surgery, 20% are found to be unresectable
• Reassess after neoadjuvant regarding resectability
ADJUVANT
Study R1 resection Arm A (survival-mo)
Arm B (survival-mo)
P-value
GITSG 1985 0 5FU/XRT 21
Observe 10.9
0.035
EORTC 1999 19 5FU/XRT 17.1
Observe 12.6
0.099
ESPAC-1 2004 18 5FU/LV 20.1
5FU/XRT 15.9
No 5FU/LV 15.5
No 5FU/XRT 17.9
0.009
0.05
RTOG 9704 2008
>35 Gem+5FU/RT 20.5
FU + FU/RT 16.9
0.09
CONKO 001 2008
19 Gem 22.8
Observe 20.2
0.005
ESPAC1+3 2009 25 5FU/LV 23.2
Observe 16.8
0.003
ESPAC 3 35 Gem 23.6
5FU/LV 23
0.39
Potentially resectable
• Carefully select for surgery
• Always attempt to give adjuvant chemo
• Adjuvant RT is may be added (RTOG 9704)
• Neoadjuvant for very selective cases
Cancer site review - methods
• We looked at all patients who were diagnosed with pancreatic cancer as per our tumor registry records from 2006 to 2012
• All charts were retrospectively reviewed for details
• 308 patients were screened
• 280 confirmed to have pancreatic adenocarcinoma and were reviewed in detail
Epidemiology
• 4th leading cause of cancer death in US
• Estimated new cases and deaths 2013:
– Cases 45,220
– Deaths 38,460
Stroger
47
41
32 36
41 41 41
0
10
20
30
40
50
60
2006 2007 2008 2009 2010 2011 2012
Cases
Cases
2010 numbers
US IL COOK COUNTY STROGER HOSP
DIAGNOSED 38,142 1705 727 41
DEATH 35,064 1494 635 23 **
There are 120 hospitals with adult patient intake in Cook County area We diagnose 5.6 % of all the cook county cases at Stroger
** The exact number unknown
Stroger (n=279)
0 0.7
5.7
30.1
37.9
18.6
5.7
1 0
5
10
15
20
25
30
35
40
<20 20-34 35-44 45-54 55-64 65-74 75-84 >84
percent by age
Median Age 58
M:F ratio
US (SEER) 1.3 : 1
Stroger 1.4 : 1
53
8
19
20
Ethnicity distribution at Stroger
Black
Asian
Hispanic
White
Prognosis
• Overall survival rate 4-5%
• 5 year survival (SEER) = 6%
• For patients with small cancers (<2cm) with no extension beyond capsule of pancreas, complete surgical resection has a 5 year survival rate of 18-24%
• For patients with advanced cancers, survival at 5 years is 1%, with most patients dying within a year
Mortality data
• To an extent not complete
– Hospice follow up
– Lost to follow up
• 5 year survival = 4.6% (SEER number 6%)
– Based on available data
– 152 patients with OS data, 7 reached 5 years
– Stage differences
National numbers
Stroger
24
14 62
Stage (%)
Localized
Unresectable
Metastatic
Surgery for localized disease
• n = 66 patients with stage I or II disease
• 57 underwent surgery (86%)
• 11 patients found to have unresectable disease or incompletely resected grossly (19%)
• 46 patients underwent complete gross resection (R0/R1)
Cases and surgery by year
13 13
5
7
3
15
10
13
11
4
6
3
12
8
-1
1
3
5
7
9
11
13
15
2006 2007 2008 2009 2010 2011 2012
Cases (St I/II)
surgery attempted
Summary
• Stroger being an inner city safety net hospital diagnoses more cases of pancreatic cancer compared to other hospitals in our Cook County area
• We have a higher percentage of advanced stage cancers compared to national average, potentially explaining the small difference in survival
• Surgery is offered to most patients with localized disease except with contraindications to surgery
• 72% of patients post definitive surgery are able to receive adjuvant therapy
Challenges for future
• Better documentation of end points of patients who enroll in hospice may improve our understanding of the true OS for more patients
• Potentially we can improve on accounting for patients who are lost to follow up
Thank You