CANCER CARE NEAR YOUR COMMUNITY

The Avera Cancer Institute – bringing care, hope and healing to yourcommunity with physicians seeing cancer patients at these locations:

n Aberdeen, S.D. n Brookings, S.D. n Estherville, Iowa n Hendricks, Minn. n Luverne, Minn. n Marshall, Minn. n Milbank, S.D. n Pierre, S.D. n Pipestone, Minn. n Platte, S.D. n Rock Valley, Iowa n Sioux Center, Iowa n Spirit Lake, Iowa n Tyler, Minn. n Winner, S.D. n Worthington, Minn.

Avera Regional Cancer Centers also include: n Avera Queen of Peace Hospital, Mitchell, S.D. n Avera Sacred Heart Hospital, Yankton, S.D. n Avera St. Luke’s Hospital, Aberdeen, S.D.

Learn more about the Avera Cancer Institute – healing through compassion and technology in your community.

Please call (605) 322-3000 or (800) 657-4377, or visit www.AveraCancer.org.

2008AverA cAncer

institute A n n u A l R E p o R t

1001 East 21 StreetSioux Falls, SD 57105

ACAI-2825-OC3108

Look no further.

Sponsored by the Benedictineand Presentation Sisters

CANCER CARE NEAR YOUR COMMUNITY

The Avera Cancer Institute – bringing care, hope and healing to yourcommunity with physicians seeing cancer patients at these locations:

n Aberdeen, S.D. n Brookings, S.D. n Estherville, Iowa n Hendricks, Minn. n Luverne, Minn. n Marshall, Minn. n Milbank, S.D. n Pierre, S.D. n Pipestone, Minn. n Platte, S.D. n Rock Valley, Iowa n Sioux Center, Iowa n Spirit Lake, Iowa n Tyler, Minn. n Winner, S.D. n Worthington, Minn.

Avera Regional Cancer Centers also include: n Avera Queen of Peace Hospital, Mitchell, S.D. n Avera Sacred Heart Hospital, Yankton, S.D. n Avera St. Luke’s Hospital, Aberdeen, S.D.

Learn more about the Avera Cancer Institute – healing through compassion and technology in your community.

Please call (605) 322-3000 or (800) 657-4377, or visit www.AveraCancer.org.

2008AverA cAncer

institute A n n u A l R E p o R t

1001 East 21 StreetSioux Falls, SD 57105

ACAI-2825-OC3108

Look no further.

Sponsored by the Benedictineand Presentation Sisters

TAbLE OfCONTENTs

Letter from Fred Slunecka .......................................................................... 2

Letter from Dr. Kirsten Erickson ................................................................ 3

Look no further for advanced, comprehensive cancer care ........................ 4

Robotics offer technologically-advanced surgical options ........................... 5

Comprehensive breast health care ............................................................. 6

Accredited, experienced cancer care here in Sioux Falls ............................ 8

Oncology nurses specialize in cancer care ................................................10

Building a stronger future in oncology research ........................................11

Enhanced end-of-life care ......................................................................... 12

Outreach provides cancer care near home ............................................... 13

Array of specialties ................................................................................... 14

Endometrial cancer update and review .................................................... 16

Benefits of being a CoC-Approved Cancer Program ................................. 22

Cancer registry: 2007 Summary by Body System and Sex ...................... 23

Cancer registry: Top 10 sites of 2007 ....................................................... 25

Our MissionAvera Cancer Institute is dedicated

to providing the highest quality

of care through prevention and

early detection, evidence-based

therapies and a multidisciplinary

approach guided by the philosophy

of healing the whole person.

~1~

TAbLE OfCONTENTs

Letter from Fred Slunecka .......................................................................... 2

Letter from Dr. Kirsten Erickson ................................................................ 3

Look no further for advanced, comprehensive cancer care ........................ 4

Robotics offer technologically-advanced surgical options ........................... 5

Comprehensive breast health care ............................................................. 6

Accredited, experienced cancer care here in Sioux Falls ............................ 8

Oncology nurses specialize in cancer care ................................................10

Building a stronger future in oncology research ........................................11

Enhanced end-of-life care ......................................................................... 12

Outreach provides cancer care near home ............................................... 13

Array of specialties ................................................................................... 14

Endometrial cancer update and review .................................................... 16

Benefits of being a CoC-Approved Cancer Program ................................. 22

Cancer registry: 2007 Summary by Body System and Sex ...................... 23

Cancer registry: Top 10 sites of 2007 ....................................................... 25

Our MissionAvera Cancer Institute is dedicated

to providing the highest quality

of care through prevention and

early detection, evidence-based

therapies and a multidisciplinary

approach guided by the philosophy

of healing the whole person.

~1~

As a leader in cancer care for 26 years, we’ve continually demonstrated innovation through a full range of cancer services. Our first oncology unit opened in 1982. We constructed the region’s first free-standing comprehensive cancer center in 1990, and developed South Dakota’s only bone marrow transplant program in 1996.

Avera McKennan has experienced a 24-percent growth in cancer cases over the past five years; not because cancer is increasing at such a pace, but because more people are choosing Avera for the advanced cancer treatment they need.

Two years ago, we concluded that our current facility would be inadequate to support the growing need for cancer care services. In May 2008, we broke ground on a new Avera Cancer Institute that will take our cancer care to a whole new level. This remarkable facility is unique in many ways:

First, its size. This five-story building will have 217,000 square-feet of space – equivalent to about five acres. With a total investment of $90 million, it’s the largest project in Avera McKennan history.

Second, its scope. The Avera Cancer Institute is designed as a place of healing through an environment and programs that emphasize an integrated and holistic approach to cancer care. As the most comprehensive community cancer center in our region, the facility will offer all services under one roof – from prevention and diagnosis, to treatment and survivorship care. More efficient care delivery will translate into less time waiting and more valued time with physicians and clinical staff.

This beautiful environment of healing incorporates natural elements such as daylight, stone, wood, green areas and water features in order to create a comforting, uplifting place that inspires hope and courage.

Our programs of healing will incorporate traditional therapies based on evidence-based protocols, as well as integrative medicine and cutting-edge cancer research.

In addition, to address another growing health care need, this building will house a state-of- the-art, eight-suite outpatient surgical center.

Third, this will be a “green” building. Our mission of healing is further extended through a building philosophy to “do no harm,” either to individuals or the community at large.

Patients will receive care in an environment free from harmful chemicals or substances, with energy and water conserving principles intended to protect our environment.

As a “green building,” this project is registered with the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) program.

Fourth, we’ve designed this center as a community resource, with spaces for community meetings and the performing arts, as well as an exterior green space for the public’s enjoyment. In many ways, this building is a gift to the community of Sioux Falls.

Our vision for this world-class center is “Life’s Transformation through Grace and Technology.” Cancer is a life transforming event. Yet, through state-of-the art technology, clinical excellence and the grace of God, family and friends, one finds hope, faith and courage.

In 2010, we’ll open the largest, most comprehensive healing environment for cancer in the city of Sioux Falls, the state of South Dakota and the wider region. Thank you for your expertise, commitment and support in making cancer care of this caliber possible at Avera.

Fred SluneckaRegional PresidentAvera McKennan

~2~ ~3~

That compares to the previous record of 3,700 participants in 2007, with more than $232,000 raised. Funds support the Community Cancer Resource Library, complimentary wigs and consultations, the Cancer Fitness Rehabilitation Program, patient assistance and improved access to mammography, genetic testing and dietitian services, as well as expansion of comprehensive breast health services and cancer survivorship programs.

Prevention and early detection of cancer remain a priority, as evidenced by these campaigns: n Think Pink for Breast Health in October to

raise breast cancer awareness, and help women understand the importance of early detection.

n Melanoma Monday, through a partnership with Lewis Drug and Sioux Falls dermatologists, to provide free skin cancer screenings, and Sun Smart campaign to increase awareness for the prevention of skin cancer.

n Our ColonCare education program to stress the importance of colon cancer screening.

n The prostate screening event in partnership with Urology Associates to allow men to be screened free of charge.

I’d like to thank the physicians, clinical staff and support staff of the Avera Cancer Institute for their expertise, commitment to high standards and holistic care. We appreciate and highly value our partnership with local and regional referring physicians. Together, we are providing people of our region with cancer services that are on a par with nationally-known centers, along with compassion and concern for the whole person for a truly comprehensive care experience.

Dr. Kirsten EricksonCancer Committee ChairAvera Radiation Oncology

As chair of Avera’s Cancer Committee, I’m proud to be part of a medical team that is committed to cutting-edge, evidence-based practices for the best possible outcomes in cancer care – a team that is equally committed to the care and healing of the whole person: body, mind and spirit.

The 13 physicians of the Avera Cancer Institute work to ensure that the most progressive comprehensive cancer care is available right here in Sioux Falls. In 2007: n Our bone marrow/stem cell transplant

program gained full, three-year accreditation by FACT, the Foundation for the Accreditation of Cellular Therapy. We are now accredited for allogeneic transplantation, as well as autologous transplantation which we achieved three years earlier in the first phase of our accreditation process.

n We established our first tumor-specific program with our comprehensive breast program.

n Gynecologic oncologists and urologists began using robotics for minimally invasive treatment of gynecologic and prostate cancers.

n Serving as medical officer, Dr. David Elson provided leadership in implementing Avera McKennan’s electronic medical record.

n Physicians in collaboration with ACI staff continued to develop survivorship programs and integrative therapies to enhance our patients’ quality of life, and care for the whole person.

n We continued to advance the research aspect of cancer care by participating in numerous clinical trials and industry studies.

n We expanded palliative care through our new state-of-the-art Dougherty Hospice House.

Avera McKennan, along with the Avera Cancer Institute, continues to be approved by the American College of Surgeons Commission on Cancer as a Community Hospital Comprehensive Cancer Program with Commendation. This represents the high level of dedication of our physicians and staff as well as the outstanding quality of our cancer program. This year marks the 22nd year our cancer program has been approved.

The 20th annual Avera Race Against Breast Cancer on May 10, 2008, was a huge success. The Race drew 4,565 participants, raising more than $275,000.

As a leader in cancer care for 26 years, we’ve continually demonstrated innovation through a full range of cancer services. Our first oncology unit opened in 1982. We constructed the region’s first free-standing comprehensive cancer center in 1990, and developed South Dakota’s only bone marrow transplant program in 1996.

Avera McKennan has experienced a 24-percent growth in cancer cases over the past five years; not because cancer is increasing at such a pace, but because more people are choosing Avera for the advanced cancer treatment they need.

Two years ago, we concluded that our current facility would be inadequate to support the growing need for cancer care services. In May 2008, we broke ground on a new Avera Cancer Institute that will take our cancer care to a whole new level. This remarkable facility is unique in many ways:

First, its size. This five-story building will have 217,000 square-feet of space – equivalent to about five acres. With a total investment of $90 million, it’s the largest project in Avera McKennan history.

Second, its scope. The Avera Cancer Institute is designed as a place of healing through an environment and programs that emphasize an integrated and holistic approach to cancer care. As the most comprehensive community cancer center in our region, the facility will offer all services under one roof – from prevention and diagnosis, to treatment and survivorship care. More efficient care delivery will translate into less time waiting and more valued time with physicians and clinical staff.

This beautiful environment of healing incorporates natural elements such as daylight, stone, wood, green areas and water features in order to create a comforting, uplifting place that inspires hope and courage.

Our programs of healing will incorporate traditional therapies based on evidence-based protocols, as well as integrative medicine and cutting-edge cancer research.

In addition, to address another growing health care need, this building will house a state-of- the-art, eight-suite outpatient surgical center.

Third, this will be a “green” building. Our mission of healing is further extended through a building philosophy to “do no harm,” either to individuals or the community at large.

Patients will receive care in an environment free from harmful chemicals or substances, with energy and water conserving principles intended to protect our environment.

As a “green building,” this project is registered with the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) program.

Fourth, we’ve designed this center as a community resource, with spaces for community meetings and the performing arts, as well as an exterior green space for the public’s enjoyment. In many ways, this building is a gift to the community of Sioux Falls.

Our vision for this world-class center is “Life’s Transformation through Grace and Technology.” Cancer is a life transforming event. Yet, through state-of-the art technology, clinical excellence and the grace of God, family and friends, one finds hope, faith and courage.

In 2010, we’ll open the largest, most comprehensive healing environment for cancer in the city of Sioux Falls, the state of South Dakota and the wider region. Thank you for your expertise, commitment and support in making cancer care of this caliber possible at Avera.

Fred SluneckaRegional PresidentAvera McKennan

~2~ ~3~

That compares to the previous record of 3,700 participants in 2007, with more than $232,000 raised. Funds support the Community Cancer Resource Library, complimentary wigs and consultations, the Cancer Fitness Rehabilitation Program, patient assistance and improved access to mammography, genetic testing and dietitian services, as well as expansion of comprehensive breast health services and cancer survivorship programs.

Prevention and early detection of cancer remain a priority, as evidenced by these campaigns: n Think Pink for Breast Health in October to

raise breast cancer awareness, and help women understand the importance of early detection.

n Melanoma Monday, through a partnership with Lewis Drug and Sioux Falls dermatologists, to provide free skin cancer screenings, and Sun Smart campaign to increase awareness for the prevention of skin cancer.

n Our ColonCare education program to stress the importance of colon cancer screening.

n The prostate screening event in partnership with Urology Associates to allow men to be screened free of charge.

I’d like to thank the physicians, clinical staff and support staff of the Avera Cancer Institute for their expertise, commitment to high standards and holistic care. We appreciate and highly value our partnership with local and regional referring physicians. Together, we are providing people of our region with cancer services that are on a par with nationally-known centers, along with compassion and concern for the whole person for a truly comprehensive care experience.

Dr. Kirsten EricksonCancer Committee ChairAvera Radiation Oncology

As chair of Avera’s Cancer Committee, I’m proud to be part of a medical team that is committed to cutting-edge, evidence-based practices for the best possible outcomes in cancer care – a team that is equally committed to the care and healing of the whole person: body, mind and spirit.

The 13 physicians of the Avera Cancer Institute work to ensure that the most progressive comprehensive cancer care is available right here in Sioux Falls. In 2007: n Our bone marrow/stem cell transplant

program gained full, three-year accreditation by FACT, the Foundation for the Accreditation of Cellular Therapy. We are now accredited for allogeneic transplantation, as well as autologous transplantation which we achieved three years earlier in the first phase of our accreditation process.

n We established our first tumor-specific program with our comprehensive breast program.

n Gynecologic oncologists and urologists began using robotics for minimally invasive treatment of gynecologic and prostate cancers.

n Serving as medical officer, Dr. David Elson provided leadership in implementing Avera McKennan’s electronic medical record.

n Physicians in collaboration with ACI staff continued to develop survivorship programs and integrative therapies to enhance our patients’ quality of life, and care for the whole person.

n We continued to advance the research aspect of cancer care by participating in numerous clinical trials and industry studies.

n We expanded palliative care through our new state-of-the-art Dougherty Hospice House.

Avera McKennan, along with the Avera Cancer Institute, continues to be approved by the American College of Surgeons Commission on Cancer as a Community Hospital Comprehensive Cancer Program with Commendation. This represents the high level of dedication of our physicians and staff as well as the outstanding quality of our cancer program. This year marks the 22nd year our cancer program has been approved.

The 20th annual Avera Race Against Breast Cancer on May 10, 2008, was a huge success. The Race drew 4,565 participants, raising more than $275,000.

Our cancer program has earned national approval from the Commission on Cancer of the American College of Surgeons for 22 years. According to the Commission on Cancer, receiving care through Avera means that patients have access to: n Quality care in or near their own community n Comprehensive care offering a range of technologically advanced, state-of-the-art

services and equipment n A multi-specialty team approach to determine the

best-possible treatment options n Cancer-related information, education and support n A cancer registry that collects data on cancer

type, stage and treatment results and offers lifelong patient follow-up

n Continuous monitoring and enhanced care n Information about ongoing cancer clinical

trials and new treatment options

Avera leads the way in all aspects of fighting this disease through expert specialists, advanced technology, and the entire strength of the Avera system – the largest health network in our region.

Nationwide, 65 percent of the approximately

90,000 prostatectomies performed this year

will incorporate the use of robotics.

Why are surgeons adapting so quickly to this innovative technology?

“The main advantages to the patient are a shorter hospital stay and quicker recovery. Those who undergo the robotic procedure will feel back to their normal selves months sooner than with the open technique,” said Dr. David Rosinsky of Urology Specialists Chartered in Sioux Falls, one of 16 surgeons trained to perform minimally invasive robotics procedures at Avera McKennan using the Da Vinci® S HD Surgical System. Other procedures include hysterectomies, advanced gynecological surgeries, Nissen fundoplication for acid reflux patients and more.

Prostatectomy, surgical removal the prostate gland, is a common treatment for men diagnosed with early-stage prostate cancer. With more than 218,000 new cases nationwide each year, prostate cancer is the most frequently diagnosed cancer in men.

The technique allows surgeons to spare nerves in the pelvic region, helping to preserve urinary continence and sexual function. “Nerves are under 10 times magnification, and the robotic arms are very precise, making it easier for the surgeon to identify those nerves,” Dr. Rosinsky said. The latest technology of three-dimensional, high-definition visualization provides improved clarity and detail.

A v E R A C A n C E R I n S T I T u T E

LOOk NO fURThER fOR AdvANCEd, COMpREhENsIvE CANCER CAREA cancer care leader since 1982,

the Avera Cancer Institute is the largest,

most experienced team offering

comprehensive oncology, hematology

and bone marrow transplant services

to the people of our region.

Robotics offers technologically advanced surgical options

The equipment is a two-part device. The patient side cart used for the actual surgery has four robotic arms. One holds a camera, the other three control miniaturized surgical instruments. Robotic arms can move in all angles, providing for increased precision. The surgeon works at a separate console, looking through an eyepiece to see magnified, 3-D imaging with real depth perception. The surgeon controls robotic devices through finger holds. “Every movement you make is transferred to the device in the patient,” Dr. Rosinsky said.

At the same time, robotic and computer technologies scale, filter and translate the surgeon’s hand movements into precise micro-movements of the surgical instruments. Robotics equipment doesn’t replace human surgeons – rather it enhances their ability to perform complex minimally invasive surgery.

nationwide, 1.4 million people will be

diagnosed with cancer this year –

4,000 in south dakota.

The Avera Cancer Institute is a regional destination for prevention, diagnosis, treatment, support, rehabilitation and survivorship care in a healing environment, with the latest in technology.

The Avera Cancer Institute offers cutting-edge services not commonly seen in a community cancer center, such as bone marrow transplant and a comprehensive breast program.

We are the region’s first recipient of the American Cancer Society’s Corporate Crown Award, which recognizes leadership, initiative, program creativity and an overall positive impact on the effects of cancer for citizens of the South Dakota region.

~4~ ~5~

Our cancer program has earned national approval from the Commission on Cancer of the American College of Surgeons for 22 years. According to the Commission on Cancer, receiving care through Avera means that patients have access to: n Quality care in or near their own community n Comprehensive care offering a range of technologically advanced, state-of-the-art

services and equipment n A multi-specialty team approach to determine the

best-possible treatment options n Cancer-related information, education and support n A cancer registry that collects data on cancer

type, stage and treatment results and offers lifelong patient follow-up

n Continuous monitoring and enhanced care n Information about ongoing cancer clinical

trials and new treatment options

Avera leads the way in all aspects of fighting this disease through expert specialists, advanced technology, and the entire strength of the Avera system – the largest health network in our region.

Nationwide, 65 percent of the approximately

90,000 prostatectomies performed this year

will incorporate the use of robotics.

Why are surgeons adapting so quickly to this innovative technology?

“The main advantages to the patient are a shorter hospital stay and quicker recovery. Those who undergo the robotic procedure will feel back to their normal selves months sooner than with the open technique,” said Dr. David Rosinsky of Urology Specialists Chartered in Sioux Falls, one of 16 surgeons trained to perform minimally invasive robotics procedures at Avera McKennan using the Da Vinci® S HD Surgical System. Other procedures include hysterectomies, advanced gynecological surgeries, Nissen fundoplication for acid reflux patients and more.

Prostatectomy, surgical removal the prostate gland, is a common treatment for men diagnosed with early-stage prostate cancer. With more than 218,000 new cases nationwide each year, prostate cancer is the most frequently diagnosed cancer in men.

The technique allows surgeons to spare nerves in the pelvic region, helping to preserve urinary continence and sexual function. “Nerves are under 10 times magnification, and the robotic arms are very precise, making it easier for the surgeon to identify those nerves,” Dr. Rosinsky said. The latest technology of three-dimensional, high-definition visualization provides improved clarity and detail.

A v E R A C A n C E R I n S T I T u T E

LOOk NO fURThER fOR AdvANCEd, COMpREhENsIvE CANCER CAREA cancer care leader since 1982,

the Avera Cancer Institute is the largest,

most experienced team offering

comprehensive oncology, hematology

and bone marrow transplant services

to the people of our region.

Robotics offers technologically advanced surgical options

The equipment is a two-part device. The patient side cart used for the actual surgery has four robotic arms. One holds a camera, the other three control miniaturized surgical instruments. Robotic arms can move in all angles, providing for increased precision. The surgeon works at a separate console, looking through an eyepiece to see magnified, 3-D imaging with real depth perception. The surgeon controls robotic devices through finger holds. “Every movement you make is transferred to the device in the patient,” Dr. Rosinsky said.

At the same time, robotic and computer technologies scale, filter and translate the surgeon’s hand movements into precise micro-movements of the surgical instruments. Robotics equipment doesn’t replace human surgeons – rather it enhances their ability to perform complex minimally invasive surgery.

nationwide, 1.4 million people will be

diagnosed with cancer this year –

4,000 in south dakota.

The Avera Cancer Institute is a regional destination for prevention, diagnosis, treatment, support, rehabilitation and survivorship care in a healing environment, with the latest in technology.

The Avera Cancer Institute offers cutting-edge services not commonly seen in a community cancer center, such as bone marrow transplant and a comprehensive breast program.

We are the region’s first recipient of the American Cancer Society’s Corporate Crown Award, which recognizes leadership, initiative, program creativity and an overall positive impact on the effects of cancer for citizens of the South Dakota region.

~4~ ~5~

Thanks to our fully-integrated Breast Center, women receive the comprehensive, supportive care they need, every step of the way. The Avera McKennan Breast Center is the region’s best resource for patient-centered care, from education, screening and diagnosis to treatment and survivorship care.

Our comprehensive breast program includes:n State-of-the-art detection of breast cancer with

digital mammography and breast magnetic resonance imaging (MRI)

n Personal attention to individual needs by a breast health navigator

n An interdisciplinary team of dedicated physicians and staff which meets weekly to review each case and create an individual treatment plan

n Education and supportn Prevention through genetic testingn Advanced treatment optionsn Region’s only comprehensive rehabilitation programs

Patients newly diagnosed with breast cancer may feel

overwhelmed or unsure. Yet, at the Avera Cancer Institute,

a supportive team of professionals accompanies each and

every patient throughout their journey.

The Avera McKennan Breast Center’s Breast Health Navigator is Carole Chell, a certified nurse practitioner. She serves as a knowledgeable, supportive guide for patients from the time of initial diagnosis through their treatment, follow-up care and survivorship.

The navigator provides education and support for decision making in every phase of the treatment and recovery process.

“Breast cancer patients receive multi-modality treatment,” Chell said, through multiple health care providers including primary care physicians, oncologists and surgeons. “As one constant in their treatment, I am someone who can help answer questions or clarify information for the patient.”

ThE BEST vIEW AnD ThE BEST REvIEW

ThE AvERA CANCER INsTITUTE bREAsT CONfERENCE

EARLY dETECTION fOR ThE bEsT OUTCOMEs

One in eight women will be diagnosed with breast

cancer in her lifetime.

For women who have a family history of breast cancer, or those with certain genetic predispositions, the risk is even higher. Yet, survivorship rates are higher than ever, making regular screening and early detection key to successful treatment.

Full-field digital mammography is the best general screening tool for detecting breast cancer. Avera McKennan offers this service to all patients who fall into mammography guidelines.

Avera McKennan is the first health provider in the region to offer breast MRI through advanced 3 Tesla MRI technology. Because it provides the clearest images available, the American Cancer Society now recommends breast MRI as a screening mode for high-risk patients.

A second opinion – as well as a third, fourth or fifth – with no additional office calls or charges. This is what every breast cancer patient receives through the Breast Conference at the Avera Cancer Institute.

This multidisciplinary conference convenes weekly to review each newly diagnosed patient’s case. Together, this team ensures that every treatment option is explored and that all patients are supported by the combined strength of the Avera McKennan Breast Center team.

Each Breast Conference is composed of an array of professionals, including pathologists, radiologists, surgeons and plastic surgeons, medical and radiation oncologists, primary care physicians, nurses, technologists and social workers.

“As breast health navigator, I hear from a lot of women who wonder if they’re doing the right thing in selecting a treatment option,” said Carole Chell, CnP, breast health navigator. Women now have the benefit of a consensus recommendation from the breast conference to back up their treatment decisions. “That provides real peace of mind for patients.”

Helping patients find their way.

Comprehensive Breast Health Care

~6~ ~7~

Thanks to our fully-integrated Breast Center, women receive the comprehensive, supportive care they need, every step of the way. The Avera McKennan Breast Center is the region’s best resource for patient-centered care, from education, screening and diagnosis to treatment and survivorship care.

Our comprehensive breast program includes:n State-of-the-art detection of breast cancer with

digital mammography and breast magnetic resonance imaging (MRI)

n Personal attention to individual needs by a breast health navigator

n An interdisciplinary team of dedicated physicians and staff which meets weekly to review each case and create an individual treatment plan

n Education and supportn Prevention through genetic testingn Advanced treatment optionsn Region’s only comprehensive rehabilitation programs

Patients newly diagnosed with breast cancer may feel

overwhelmed or unsure. Yet, at the Avera Cancer Institute,

a supportive team of professionals accompanies each and

every patient throughout their journey.

The Avera McKennan Breast Center’s Breast Health Navigator is Carole Chell, a certified nurse practitioner. She serves as a knowledgeable, supportive guide for patients from the time of initial diagnosis through their treatment, follow-up care and survivorship.

The navigator provides education and support for decision making in every phase of the treatment and recovery process.

“Breast cancer patients receive multi-modality treatment,” Chell said, through multiple health care providers including primary care physicians, oncologists and surgeons. “As one constant in their treatment, I am someone who can help answer questions or clarify information for the patient.”

ThE BEST vIEW AnD ThE BEST REvIEW

ThE AvERA CANCER INsTITUTE bREAsT CONfERENCE

EARLY dETECTION fOR ThE bEsT OUTCOMEs

One in eight women will be diagnosed with breast

cancer in her lifetime.

For women who have a family history of breast cancer, or those with certain genetic predispositions, the risk is even higher. Yet, survivorship rates are higher than ever, making regular screening and early detection key to successful treatment.

Full-field digital mammography is the best general screening tool for detecting breast cancer. Avera McKennan offers this service to all patients who fall into mammography guidelines.

Avera McKennan is the first health provider in the region to offer breast MRI through advanced 3 Tesla MRI technology. Because it provides the clearest images available, the American Cancer Society now recommends breast MRI as a screening mode for high-risk patients.

A second opinion – as well as a third, fourth or fifth – with no additional office calls or charges. This is what every breast cancer patient receives through the Breast Conference at the Avera Cancer Institute.

This multidisciplinary conference convenes weekly to review each newly diagnosed patient’s case. Together, this team ensures that every treatment option is explored and that all patients are supported by the combined strength of the Avera McKennan Breast Center team.

Each Breast Conference is composed of an array of professionals, including pathologists, radiologists, surgeons and plastic surgeons, medical and radiation oncologists, primary care physicians, nurses, technologists and social workers.

“As breast health navigator, I hear from a lot of women who wonder if they’re doing the right thing in selecting a treatment option,” said Carole Chell, CnP, breast health navigator. Women now have the benefit of a consensus recommendation from the breast conference to back up their treatment decisions. “That provides real peace of mind for patients.”

Helping patients find their way.

Comprehensive Breast Health Care

~6~ ~7~

A v E R A C A n C E R I n S T I T u T EB O n E M A R R O W T R A n S P L A n T P R O g R A M

ACCREdITEd, ExpERIENCEd CANCER CARE hERE IN sIOUx fALLs

Allogeneic transplants are similar, but involve the transplantation of stem cells from a close relative, or someone who is a close match. People with certain types of leukemia can benefit from this treatment, because their own stem cells carry the genetic mutation that caused cancer in the first place.

The latest advancements in bone marrow transplant involve better chemotherapy drugs, and better supportive care to handle side effects and adverse reactions. For example, Avera offers photopheresis, a newly-approved treatment for graft-versus-host disease, in which the body’s immune system fights the new stem cells. Through this technology, blood components are separated, and white cells are combined with a drug and passed between two photo panels to activate the drug.

Whereas bone marrow transplant used to be a last resort, it is now a first-line treatment for certain cancers of the blood and lymphatic system, because it is not only a treatment which can bring about remission, it can be a cure. “It gives people real hope,” Dr. Medlin said, people like Irene Rezac, who had a stem cell transplant five years ago to treat a recurrence of lymphoma.

Since her transplant on Aug. 20, 2003 – the date she calls her “second birthday” – she’s been able to enjoy time with children, grandchildren and great-grandchildren. “I’m just so thankful to be here,” she said. “I don’t think I could have had better doctors. It was so nice to have my transplant done here at Avera and not have to travel out of town.”

“Our strength is giving high-

quality care in a personalized

fashion,” said Dr. Stephen Medlin,

hematologist with Avera

Hematology and Transplant.

“Patients are not just a number.

Our staff is very friendly and

supportive. Patients know their

physicians and nurses on a

personal level. It’s nice to have

people caring for you who

know who you are.”

The Avera team combines the best evidence-based protocols with personal, individualized care.

Although a standard treatment for cancers such as leukemia, lymphoma and multiple myeloma, bone marrow transplant is commonly provided only at large metropolitan centers. For 12 years, however, the same life-saving care has been available right here in Sioux Falls at the Avera Cancer Institute.

Part of the Avera Transplant Institute, the state’s and region’s first and only bone marrow transplant program has outcomes which meet or exceed national and international standards. The program is three physicians strong, and is fully-accredited through the Foundation for the Accreditation of Cellular Therapy (FACT). Since the program began in 1996, more than 225 bone marrow transplants have been performed.

The program also meets requirements for participation in the National Marrow Donor Program for unrelated donor transplants.

FACT accreditation was first gained in 2004 for autologous transplantation, with a three-year expansion of that accreditation in 2007 for both autologous and allogeneic adult transplantation.

While accreditation is voluntary, it holds the program to the highest possible standard. “Transplantation is a complex process that can involve serious complications,” said Dr. Vinod Parameswaran, hematologist with Avera Hematology and Transplant.

Accreditation ensures that programs are using the best practices and treatment protocols. “People can be assured that they will receive care equivalent to any other bone marrow transplant center across the United States,” Dr. Parameswaran said. “The best of care can be delivered right here.”

Bone marrow transplants fall into two main categories: Autologous and allogeneic stem cell transplants. Autologous transplants involve harvesting a patient’s own stem cells,delivering high doses of chemotherapy, and then giving the patient back his or her own stem cells, which will result in the normal growth of new blood cells. This mode is standard care for multiple myeloma, and is effective for certain types of lymphoma.

~8~ ~9~

A v E R A C A n C E R I n S T I T u T EB O n E M A R R O W T R A n S P L A n T P R O g R A M

ACCREdITEd, ExpERIENCEd CANCER CARE hERE IN sIOUx fALLs

Allogeneic transplants are similar, but involve the transplantation of stem cells from a close relative, or someone who is a close match. People with certain types of leukemia can benefit from this treatment, because their own stem cells carry the genetic mutation that caused cancer in the first place.

The latest advancements in bone marrow transplant involve better chemotherapy drugs, and better supportive care to handle side effects and adverse reactions. For example, Avera offers photopheresis, a newly-approved treatment for graft-versus-host disease, in which the body’s immune system fights the new stem cells. Through this technology, blood components are separated, and white cells are combined with a drug and passed between two photo panels to activate the drug.

Whereas bone marrow transplant used to be a last resort, it is now a first-line treatment for certain cancers of the blood and lymphatic system, because it is not only a treatment which can bring about remission, it can be a cure. “It gives people real hope,” Dr. Medlin said, people like Irene Rezac, who had a stem cell transplant five years ago to treat a recurrence of lymphoma.

Since her transplant on Aug. 20, 2003 – the date she calls her “second birthday” – she’s been able to enjoy time with children, grandchildren and great-grandchildren. “I’m just so thankful to be here,” she said. “I don’t think I could have had better doctors. It was so nice to have my transplant done here at Avera and not have to travel out of town.”

“Our strength is giving high-

quality care in a personalized

fashion,” said Dr. Stephen Medlin,

hematologist with Avera

Hematology and Transplant.

“Patients are not just a number.

Our staff is very friendly and

supportive. Patients know their

physicians and nurses on a

personal level. It’s nice to have

people caring for you who

know who you are.”

The Avera team combines the best evidence-based protocols with personal, individualized care.

Although a standard treatment for cancers such as leukemia, lymphoma and multiple myeloma, bone marrow transplant is commonly provided only at large metropolitan centers. For 12 years, however, the same life-saving care has been available right here in Sioux Falls at the Avera Cancer Institute.

Part of the Avera Transplant Institute, the state’s and region’s first and only bone marrow transplant program has outcomes which meet or exceed national and international standards. The program is three physicians strong, and is fully-accredited through the Foundation for the Accreditation of Cellular Therapy (FACT). Since the program began in 1996, more than 225 bone marrow transplants have been performed.

The program also meets requirements for participation in the National Marrow Donor Program for unrelated donor transplants.

FACT accreditation was first gained in 2004 for autologous transplantation, with a three-year expansion of that accreditation in 2007 for both autologous and allogeneic adult transplantation.

While accreditation is voluntary, it holds the program to the highest possible standard. “Transplantation is a complex process that can involve serious complications,” said Dr. Vinod Parameswaran, hematologist with Avera Hematology and Transplant.

Accreditation ensures that programs are using the best practices and treatment protocols. “People can be assured that they will receive care equivalent to any other bone marrow transplant center across the United States,” Dr. Parameswaran said. “The best of care can be delivered right here.”

Bone marrow transplants fall into two main categories: Autologous and allogeneic stem cell transplants. Autologous transplants involve harvesting a patient’s own stem cells,delivering high doses of chemotherapy, and then giving the patient back his or her own stem cells, which will result in the normal growth of new blood cells. This mode is standard care for multiple myeloma, and is effective for certain types of lymphoma.

~8~ ~9~

“Just as it’s important that physicians have credentials, we feel it’s important that oncology nurses be certified in their specialty,” said Lola Twedt, RN, OCN, oncology clinical nurse educator at Avera McKennan.

Among nurses eligible for certification, 60 percent of outpatient nurses at the Avera Cancer Institute and 28 percent of inpatient oncology nurses at Avera McKennan hold the OCN designation through the Oncology Nursing Certification Corporation.

Certification demonstrates commitment above and beyond that of an RN to gain specialized knowledge, clinical competence and professional credibility. “We work in a very specialized unit. New drugs are being introduced all the time, so we need to know what side effects or complications to watch for,” said Kristy Popkes, RN, OCN, oncology nurse at Avera McKennan.

With 10 years of experience, the Avera Research Institute has developed a strong presence in cancer research in the region.

With more than 50 new and ongoing clinical studies to test new treatments, drugs or combinations of drugs in cancer care, this presence was never more demonstrated than in 2007.

In June 2007, the Avera Research Institute became the first location in the world to be initiated as a site to participate in a lung cancer study treating patients with advanced lung cancer with two approved chemotherapy drugs plus an experimental oral medication. While chemotherapy is designed to kill rapidly growing cells, this medication acts to prevent the growth of blood vessels that promote the growth of the tumor.

The Avera Research Institute also opened its first Phase 1 study, which measures the combination of an investigational medication with conventional chemotherapy drugs. The study is designed for patients with multiple myeloma, an incurable but treatable cancer diagnosed most often in people age 65 and older.

bUILdING A sTRONGER fUTURE IN ONCOLOGY REsEARCh“The investigational medication is an antibody that actually targets proteins on myeloma cells,” said Dr. R. vinod Parameswaran, hematologist with Avera hematology and Transplant and principal investigator for the study. “The goal is complete remission, so the patient is able to return to as normal a quality of life as possible.”

Trials are the first step in finding new treatments for the future, and offer additional options to patients who do not respond to traditional treatment – patients like Joe Donnelly, a 73-year-old resident of Elk Point, S.D. who was bound for hospice care before taking part in an acute myelogenous leukemia study. he is now in remission. While he still receives treatment for a pre-leukemia condition known as myelodysplastic syndrome, he enjoys a better quality of life – and hope for a longer life. “I feel good,” he said, “and I have some hope.”

Through a partnership with the Avera Research Institute, Avera Cancer Institute patients will continue to have access to several new studies, sponsored either through the national Cancer Institute or through pharmaceutical companies. These studies will involve patients with breast cancer; lymphoma; cancers of the lung, colon, head and neck; myelodysplastic syndrome; and leukemia.

“We’re all on one team committed to offering innovative treatments to cancer patients,” said Jessica Larsen-gallup, an oncology research coordinator. “It’s exciting to think what the future will bring.”

for a list of current research trials, visit www.Avera-Research.org.

“We are caring for them at one of the most vulnerable points in their lives. Cancer patients and their families are so courageous.” - Kristy Popkes, oncology nurse at Avera McKennan

Aside from certification, all oncology nurses must pass the Oncology Nursing Society’s chemotherapy provider course in order to administer chemotherapy. Avera offers the only ONS chemotherapy certification course in the area, training nurses from the surrounding area. In addition, Avera offers bone marrow transplant classes for health professionals in all disciplines.

Outpatient oncology nurse Michelle Berreth, RN, CRNI, at the Avera Cancer Institute has been a nurse for 26 years, spending 16 of those years working with cancer patients in medical oncology, radiation oncology and home infusion. Certified in infusion, she is a past board member of the Infusion Nursing Society. “I can’t imagine doing anything else,” Berreth said of her career choice in oncology nursing. “I believe that in life, you’re supposed to give back. For me, this is the best way to do it.”

Because oncology nurses see their patients on a regular basis for long periods of time, a special rapport develops. “Being able to journey with these patients is a calling, a ministry…a spiritual walk for me,” said Patti Swenson, RN, oncology nurse in the Avera Hematology and Transplant infusion center.

O n C O L O g Y n u R S E S

spECIALIzE IN CANCER CARE

OnCOLOgY nuRSES AT

AvERA ARE A vITAL PART

OF ThE TEAM In PROvIDIng

ThE hIghEST POSSIBLE QuALITY

OF CARE TO CAnCER PATIEnTS.

A v E R A R E S E A R C h I n S T I T u T E

~10~ ~11~

“Just as it’s important that physicians have credentials, we feel it’s important that oncology nurses be certified in their specialty,” said Lola Twedt, RN, OCN, oncology clinical nurse educator at Avera McKennan.

Among nurses eligible for certification, 60 percent of outpatient nurses at the Avera Cancer Institute and 28 percent of inpatient oncology nurses at Avera McKennan hold the OCN designation through the Oncology Nursing Certification Corporation.

Certification demonstrates commitment above and beyond that of an RN to gain specialized knowledge, clinical competence and professional credibility. “We work in a very specialized unit. New drugs are being introduced all the time, so we need to know what side effects or complications to watch for,” said Kristy Popkes, RN, OCN, oncology nurse at Avera McKennan.

With 10 years of experience, the Avera Research Institute has developed a strong presence in cancer research in the region.

With more than 50 new and ongoing clinical studies to test new treatments, drugs or combinations of drugs in cancer care, this presence was never more demonstrated than in 2007.

In June 2007, the Avera Research Institute became the first location in the world to be initiated as a site to participate in a lung cancer study treating patients with advanced lung cancer with two approved chemotherapy drugs plus an experimental oral medication. While chemotherapy is designed to kill rapidly growing cells, this medication acts to prevent the growth of blood vessels that promote the growth of the tumor.

The Avera Research Institute also opened its first Phase 1 study, which measures the combination of an investigational medication with conventional chemotherapy drugs. The study is designed for patients with multiple myeloma, an incurable but treatable cancer diagnosed most often in people age 65 and older.

bUILdING A sTRONGER fUTURE IN ONCOLOGY REsEARCh“The investigational medication is an antibody that actually targets proteins on myeloma cells,” said Dr. R. vinod Parameswaran, hematologist with Avera hematology and Transplant and principal investigator for the study. “The goal is complete remission, so the patient is able to return to as normal a quality of life as possible.”

Trials are the first step in finding new treatments for the future, and offer additional options to patients who do not respond to traditional treatment – patients like Joe Donnelly, a 73-year-old resident of Elk Point, S.D. who was bound for hospice care before taking part in an acute myelogenous leukemia study. he is now in remission. While he still receives treatment for a pre-leukemia condition known as myelodysplastic syndrome, he enjoys a better quality of life – and hope for a longer life. “I feel good,” he said, “and I have some hope.”

Through a partnership with the Avera Research Institute, Avera Cancer Institute patients will continue to have access to several new studies, sponsored either through the national Cancer Institute or through pharmaceutical companies. These studies will involve patients with breast cancer; lymphoma; cancers of the lung, colon, head and neck; myelodysplastic syndrome; and leukemia.

“We’re all on one team committed to offering innovative treatments to cancer patients,” said Jessica Larsen-gallup, an oncology research coordinator. “It’s exciting to think what the future will bring.”

for a list of current research trials, visit www.Avera-Research.org.

“We are caring for them at one of the most vulnerable points in their lives. Cancer patients and their families are so courageous.” - Kristy Popkes, oncology nurse at Avera McKennan

Aside from certification, all oncology nurses must pass the Oncology Nursing Society’s chemotherapy provider course in order to administer chemotherapy. Avera offers the only ONS chemotherapy certification course in the area, training nurses from the surrounding area. In addition, Avera offers bone marrow transplant classes for health professionals in all disciplines.

Outpatient oncology nurse Michelle Berreth, RN, CRNI, at the Avera Cancer Institute has been a nurse for 26 years, spending 16 of those years working with cancer patients in medical oncology, radiation oncology and home infusion. Certified in infusion, she is a past board member of the Infusion Nursing Society. “I can’t imagine doing anything else,” Berreth said of her career choice in oncology nursing. “I believe that in life, you’re supposed to give back. For me, this is the best way to do it.”

Because oncology nurses see their patients on a regular basis for long periods of time, a special rapport develops. “Being able to journey with these patients is a calling, a ministry…a spiritual walk for me,” said Patti Swenson, RN, oncology nurse in the Avera Hematology and Transplant infusion center.

O n C O L O g Y n u R S E S

spECIALIzE IN CANCER CARE

OnCOLOgY nuRSES AT

AvERA ARE A vITAL PART

OF ThE TEAM In PROvIDIng

ThE hIghEST POSSIBLE QuALITY

OF CARE TO CAnCER PATIEnTS.

A v E R A R E S E A R C h I n S T I T u T E

~10~ ~11~

Newly opened in december 2007, the house marks a new age in hospice care, providing 24-hour residential and inpatient acute care in a homelike, family-centered environment.

The 25,000-square-foot, 16-bed facility is the largest hospice residence in the state of South Dakota, and the only service of its kind in the Sioux Falls area. Patients receive around-the-clock medical care in a setting that offers the warmth and security of home. The building’s design celebrates life, with an emphasis on daylight and scenic views. Throughout the house are more than 100 pieces of original art, conveying messages ofhope, dignity, joy, spirituality, comfort and concern.

The majority of hospice care through Avera McKennan is given in patients’ homes, or in the home of a family member. “But when inpatient care is a necessity, the Dougherty hospice house is a home away from home – greatly enhancing the care of individuals facing end of life and their families,” said Fred Slunecka, regional president of Avera McKennan.

That’s why the Avera Cancer

Institute places an emphasis on

outreach, with 15 oncology

outreach centers throughout

the region. four regional Avera

hospitals also offer cancer care.

An example is Aberdeen, S.D., where hematologist and bone marrow transplant specialist Dr. Kelly McCaul of Avera hematology and Transplant at the Avera Cancer Institute sees patients two days a month at Medical Oncology and hematology, the practice of Dr. Richard Conklin.

Dr. McCaul complements Dr. Conklin’s care by seeing acute leukemia patients, and those needing bone marrow transplant to treat leukemia and other types of blood-related cancers.

While patients must be at Avera McKennan in Sioux Falls for the actual bone marrow transplant, advance and follow-up visits can take place in Aberdeen. “Patients may be ill, weak or frail, making travel for them difficult. having Dr. McCaul come here to see patients helps them tremendously,” Dr. Conklin said. Local care also saves cancer patients or their families from having to lose time at work.

n E W D O u g h E R T Y h O S P I C E h O u S E

ENhANCEs ENd-Of-LIfE CARE

The Dougherty Hospice

House, located on the

grounds of Avera Prince

of Peace Retirement

Community, provides

state-of-the-art care

with comfort and dignity

at the end of life.

OUTREACh pROvIdEs CANCER CARE NEAR hOME

Patients experience convenience while saving time and money. Immediate access to specialty care for symptom management is also available to patients through telemedicine, Dr. Conklin said. “Chemotherapy patients may experience complications, such as a typical infections as their white cell counts fall. via telemedicine, a patient can see an infectious disease specialist almost immediately.”

Dr. Conklin appreciates the additional depth Dr. McCaul and other Avera specialists provide. The arrangement also gives him additional opportunity to participate in research studies. “I have an extremely busy practice, and Dr. McCaul and others within the Avera system offer me incredible support,” Dr. Conklin said.

FAMIL IAR SuRROunDIngS AnD ThE COMPAnY OF FAMILY AnD FRIEnDS hELP STREngThEn PATIEnTS In ThEIR BATTLE AgAInST CAnCER.

~12~ ~13~

Newly opened in december 2007, the house marks a new age in hospice care, providing 24-hour residential and inpatient acute care in a homelike, family-centered environment.

The 25,000-square-foot, 16-bed facility is the largest hospice residence in the state of South Dakota, and the only service of its kind in the Sioux Falls area. Patients receive around-the-clock medical care in a setting that offers the warmth and security of home. The building’s design celebrates life, with an emphasis on daylight and scenic views. Throughout the house are more than 100 pieces of original art, conveying messages ofhope, dignity, joy, spirituality, comfort and concern.

The majority of hospice care through Avera McKennan is given in patients’ homes, or in the home of a family member. “But when inpatient care is a necessity, the Dougherty hospice house is a home away from home – greatly enhancing the care of individuals facing end of life and their families,” said Fred Slunecka, regional president of Avera McKennan.

That’s why the Avera Cancer

Institute places an emphasis on

outreach, with 15 oncology

outreach centers throughout

the region. four regional Avera

hospitals also offer cancer care.

An example is Aberdeen, S.D., where hematologist and bone marrow transplant specialist Dr. Kelly McCaul of Avera hematology and Transplant at the Avera Cancer Institute sees patients two days a month at Medical Oncology and hematology, the practice of Dr. Richard Conklin.

Dr. McCaul complements Dr. Conklin’s care by seeing acute leukemia patients, and those needing bone marrow transplant to treat leukemia and other types of blood-related cancers.

While patients must be at Avera McKennan in Sioux Falls for the actual bone marrow transplant, advance and follow-up visits can take place in Aberdeen. “Patients may be ill, weak or frail, making travel for them difficult. having Dr. McCaul come here to see patients helps them tremendously,” Dr. Conklin said. Local care also saves cancer patients or their families from having to lose time at work.

n E W D O u g h E R T Y h O S P I C E h O u S E

ENhANCEs ENd-Of-LIfE CARE

The Dougherty Hospice

House, located on the

grounds of Avera Prince

of Peace Retirement

Community, provides

state-of-the-art care

with comfort and dignity

at the end of life.

OUTREACh pROvIdEs CANCER CARE NEAR hOME

Patients experience convenience while saving time and money. Immediate access to specialty care for symptom management is also available to patients through telemedicine, Dr. Conklin said. “Chemotherapy patients may experience complications, such as a typical infections as their white cell counts fall. via telemedicine, a patient can see an infectious disease specialist almost immediately.”

Dr. Conklin appreciates the additional depth Dr. McCaul and other Avera specialists provide. The arrangement also gives him additional opportunity to participate in research studies. “I have an extremely busy practice, and Dr. McCaul and others within the Avera system offer me incredible support,” Dr. Conklin said.

FAMIL IAR SuRROunDIngS AnD ThE COMPAnY OF FAMILY AnD FRIEnDS hELP STREngThEn PATIEnTS In ThEIR BATTLE AgAInST CAnCER.

~12~ ~13~

David Elson, MD, FACP

Mark Huber, MD

Michael Robinson, MD

Addison Tolentino, MD

Amy Krie, MD

A R R A Y O F

spECIALTIEs

Battling cancer requires experienced specialists, the latest technology and a variety of treatment options. Just as important is a team that understands each patient’s needs and offers compassionate care.

Our highly-skilled team of physicians, nurses, social workers, pharmacists and patient advocates develops individual treatment plans for patients with conditions including: n Solid tumors n Lymphoma n Multiple myeloma n Hypercoagulable states n Coagulation disorders

We also provide palliative care and pain control for patients with such conditions.

obstetrics & Gynecology and Gynecologic oncology

Christina Gant, CNP

Dr. Samir, Dr. Rojas and their staff provide patients with the most advanced women’s health care available, offering evaluation, diagnosis and treatment for women with gynecological cancers. The expert team uses combined therapies to treat cancer, including robotic-assisted surgery, traditional surgery, chemotherapy and radiation therapy.

Samir Abu-Ghazaleh, MD, FACOG, FACS

Luis Rojas, MD

since 1996 – The Region’s Only bone Marrow Transplant program

In association with Avera McKennan’s Transplant Institute, Avera Hematology and Transplant provides the region’s only bone marrow transplant program, through which people from a five-state area receive world-class care.

Bone marrow transplant is a standardized form of therapy for malignant and non-malignant conditions including: n Acute and chronic leukemia n Hodgkin’s and non-Hodgkin’s lymphoma n Multiple myeloma n Germ cell cancers n Myelodysplastic syndromes n Aplastic anemia

With 12 years of patient care, outcomes of the Avera McKennan Bone Marrow Transplant Program meet or exceed national and international standards for quality. The program is fully accredited.

Tammie Smart, RN, MS, CNP

Kristen Hurley, RN, MSN, CNP

Stephen Medlin, DO Kelly McCaul, MD, FRCPC

R. Vinod Parameswaran, MD, MRCP, MRCPath

Kathleen Schneekloth, MD

Bette Gustafson, CNP

Claudia Kapp, CNP

Radiation therapy is a common treatment for people with cancer. This approach can be used with other treatments, including surgery or chemotherapy.

Our highly-experienced physicians and team of professionals understand each patient has individual needs and focus on the best treatment plan to meet those needs. We follow the treatment process closely and monitor and treat side effects to ensure patients maintain the highest possible quality of life.

Treatment options include: n External beam radiation therapy n Intensity modulated radiation therapy n High-dose rate brachytherapy n Prostate seed implantation n X-Knife stereotactic radiosurgery n Total body irradiation n Mammosite breast brachytherapy

Kirsten Erickson, MD John Griffin, MD Steven McGraw, MD

~14~ ~15~

Adam Walker, CNP

David Elson, MD, FACP

Mark Huber, MD

Michael Robinson, MD

Addison Tolentino, MD

Amy Krie, MD

A R R A Y O F

spECIALTIEs

Battling cancer requires experienced specialists, the latest technology and a variety of treatment options. Just as important is a team that understands each patient’s needs and offers compassionate care.

Our highly-skilled team of physicians, nurses, social workers, pharmacists and patient advocates develops individual treatment plans for patients with conditions including: n Solid tumors n Lymphoma n Multiple myeloma n Hypercoagulable states n Coagulation disorders

We also provide palliative care and pain control for patients with such conditions.

obstetrics & Gynecology and Gynecologic oncology

Christina Gant, CNP

Dr. Samir, Dr. Rojas and their staff provide patients with the most advanced women’s health care available, offering evaluation, diagnosis and treatment for women with gynecological cancers. The expert team uses combined therapies to treat cancer, including robotic-assisted surgery, traditional surgery, chemotherapy and radiation therapy.

Samir Abu-Ghazaleh, MD, FACOG, FACS

Luis Rojas, MD

since 1996 – The Region’s Only bone Marrow Transplant program

In association with Avera McKennan’s Transplant Institute, Avera Hematology and Transplant provides the region’s only bone marrow transplant program, through which people from a five-state area receive world-class care.

Bone marrow transplant is a standardized form of therapy for malignant and non-malignant conditions including: n Acute and chronic leukemia n Hodgkin’s and non-Hodgkin’s lymphoma n Multiple myeloma n Germ cell cancers n Myelodysplastic syndromes n Aplastic anemia

With 12 years of patient care, outcomes of the Avera McKennan Bone Marrow Transplant Program meet or exceed national and international standards for quality. The program is fully accredited.

Tammie Smart, RN, MS, CNP

Kristen Hurley, RN, MSN, CNP

Stephen Medlin, DO Kelly McCaul, MD, FRCPC

R. Vinod Parameswaran, MD, MRCP, MRCPath

Kathleen Schneekloth, MD

Bette Gustafson, CNP

Claudia Kapp, CNP

Radiation therapy is a common treatment for people with cancer. This approach can be used with other treatments, including surgery or chemotherapy.

Our highly-experienced physicians and team of professionals understand each patient has individual needs and focus on the best treatment plan to meet those needs. We follow the treatment process closely and monitor and treat side effects to ensure patients maintain the highest possible quality of life.

Treatment options include: n External beam radiation therapy n Intensity modulated radiation therapy n High-dose rate brachytherapy n Prostate seed implantation n X-Knife stereotactic radiosurgery n Total body irradiation n Mammosite breast brachytherapy

Kirsten Erickson, MD John Griffin, MD Steven McGraw, MD

~14~ ~15~

Adam Walker, CNP

Endometrial cancer is the fourth most common cancer in women in the United States. A detailed understanding of the epidemiology, natural history, pathophysiology and management strategies allows the physician in a primary care role to identify women at risk, contributing to an early diagnosis and appropriate referral to the gynecologic oncologist, facilitating a favorable outcome for the patient. This document reviews the characteristics and treatment of endometrial cancer and summarizes the Avera Cancer Institute’s experience and outcomes in the management of this disease in recent years. EpidemiologyApproximately 40,100 new cases of epidemiology have been predicted and 7,470 women will expire from it in 2008.1 It is commonly diagnosed in postmenopausal women, but 25 percent of cases can be diagnosed before menopause.2 Age distribution of the patients diagnosed with endometrial cancer at the Avera Cancer Institute is similar to that reported in the literature, but less proportion of patients seem to be diagnosed in the premenopausal state (Graph 1).

The incidence rates are higher in whites, and in South Dakota, 25.8 per 100,000 women present with this disease, which is slightly higher than the prevalence for the nation.3 Women have a 2.6 percent lifetime risk of developing endometrial cancer and it accounts for 6 percent of all cancers in women. Fortunately, most cases are diagnosed at an early stage when surgery alone may be

adequate for cure.

Differences in epidemiology and prognosis suggest that two forms of endometrial cancer exist: type I endometrial carcinoma (80 percent) which is estrogen-related, usually is a low grade and favorable cell type tumor (endometrioid), and is associated with atypical endometrial hyperplasia. Common risk factors are obesity, nulliparity, estrogen excess, diabetes mellitus and hypertension. Type II endometrial cancer (20 percent), on the contrary, is unrelated to estrogen exposure or endometrial hyperplasia, and tends to be of higher grade and non-favorable cell types (clear cell and serous). Patients are often multiparous, older and are not obese, diabetic or hypertensive.4

Our current understanding of endometrial cancer risk factors only helps identify women at risk for type I endometrial cancer and are listed in Table 1. Other factors like nulliparity, diet, alcohol consumption and the age at which the patient experiences menarche and menopause, although implicated in the development of the disease, have been inconsistently determined

as independent risk factors.5–9 Factors like oral contraceptive pill use, progestin like hormonal contraception and smoking (increased liver metabolism of estrogen), are protective factors against endometrial cancer.10–12

Familial predisposition exists for certain types of endometrial cancer. Patients with hereditary nonpolyposis colorectal cancer syndrome 14-15(The Lynch syndrome II), in which the genetic hallmark is a germ-line mutation in the mismatch repair genes, are at increased risk of extra-colonic tumors, the most common of which are endometrial carcinomas (in up to 43 percent of females by age 70 in affected families). 13 Similarly, the breast cancer susceptibility gene BRCA1 may play a role in development of endometrial cancer. A multinational cohort and a prospective series have been associated with a small, but significantly increased risk of endometrial cancer for BRCA mutations carriers and carriers taking tamoxifen respectively.14-15 Further investigation on this regard is required.

Clinical presentation, diagnosis and screeningAbnormal uterine bleeding is the most common presentation and occurs in 90 percent of cases of endometrial cancer.16 Pre- and peri-menopausal events of abnormal bleeding should be evaluated for endometrial cancer, particularly if risk factors are present. The presence of benign appearing endometrial cells on cervical cancer screening is rarely associated with endometrial cancer; atypical endometrial cells, though, should alert the physician since the risk of cancer is higher when present. However, cervical cytology (Papanicolau smear) is not a screening method for endometrial cancer and it can miss 50 percent of all endometrial cancers. Furthermore, a negative cervical cytology does not rule out a cancer of the endometrium.

Endometrial cancer is a histological diagnosis, and even though non-invasive tools like ultrasonography and sonohysterography help triage women with abnormal uterine bleeding, tissue must always be obtained for diagnosis with a Pipelle, hysteroscopy and/or curettage.

General population screening in asymptomatic women for endometrial cancer is not warranted, except those with HNPCC whose risk of developing the disease is increased (40 to 60 percent). For women on tamoxifen there are no evidence-based guidelines for endometrial cancer screening; this is achieved based on symptom presentation and ultrasound findings.

Management and outcomesAccording to the joint International Federation of Gynecology and Obstetrics (FIGO)/American Joint Committee on Cancer (AJCC) classification system, endometrial cancer should be primarily surgically staged (Table 2). This surgical staging and several histologic factors obtained from it help guide the need for subsequent management with radiation and/or chemotherapy.

Endometrial cancer is usually diagnosed in the early stages (70 to 75 percent of cases are in stage I at diagnosis; 10 percent to 15 percent of cases are in stage II; 10 to 15 percent of cases are in stage III or IV). As a consequence, a better outcome is associated with it as opposed to other types of gynecological cancers, such as ovarian cancer. At the Avera Cancer Institute there seems to be a trend of increased numbers of stage III and IV and a decreased number of stage I cases at diagnosis in 2007 (Graph 2). This trend may be a reflection of the time period analyzed and reported in the current publication.

ENdOMETRIAL CANCER UpdATE ANd REvIEW

BY LuIS A. RojAS MD AnD SAMIR ABu-GHAzALEH MD, FACoG, FACS

Graph 1: The line defines median age of menopause in the united States, demonstrating a most common presentation of endometrial cancer in the postmenopausal state.

DR. LuIS RojAS DR. SAMIR ABu-GHAzALEH

Table1: Endometrial cancer risk factors

Risk factor Risk increase of endometrial cancer

unopposed estrogen therapy 2 – 10 times

Late menopause (after age 55) 2 times

nulliparity 2 times

Chronic anovulation 3 times

Obesity 2 – 4 times

Diabetes mellitus 2 times

Tamoxifen therapy 2/1000

hereditary nonpolyposis colorectal cancer 22 to 50 % lifetime risk increase

Table 2: Endometrial cancer staging.

fIGO TNM definitionstages Category

Tx Tumor can not be assessed

T0 no evidence of Tumor

Tis Carcinoma in situ (EIn)

I T1 Tumor Confined to the uterus IA T1a Limited to the endometrium IB T1b Invades < 50% of the myometrium IC T1c Invades > 50% of the myometrium

II T2 Extends to the cervix IIA T2a Only endocervical glands involved

IIB T2b Cervical stromal involvement

III T3 Local and/or regional spread IIIA T3a uterine serosa and/or adnexa and/or positive washings IIIB T3b vaginal involvement

IIIC n1 nodal metastasis to pelvic or perioartic region

IvA T4 Bladder or bowel mucosal involvement

IvB M1 Distant metastasis

~16~ ~17~

Endometrial cancer is the fourth most common cancer in women in the United States. A detailed understanding of the epidemiology, natural history, pathophysiology and management strategies allows the physician in a primary care role to identify women at risk, contributing to an early diagnosis and appropriate referral to the gynecologic oncologist, facilitating a favorable outcome for the patient. This document reviews the characteristics and treatment of endometrial cancer and summarizes the Avera Cancer Institute’s experience and outcomes in the management of this disease in recent years. EpidemiologyApproximately 40,100 new cases of epidemiology have been predicted and 7,470 women will expire from it in 2008.1 It is commonly diagnosed in postmenopausal women, but 25 percent of cases can be diagnosed before menopause.2 Age distribution of the patients diagnosed with endometrial cancer at the Avera Cancer Institute is similar to that reported in the literature, but less proportion of patients seem to be diagnosed in the premenopausal state (Graph 1).

The incidence rates are higher in whites, and in South Dakota, 25.8 per 100,000 women present with this disease, which is slightly higher than the prevalence for the nation.3 Women have a 2.6 percent lifetime risk of developing endometrial cancer and it accounts for 6 percent of all cancers in women. Fortunately, most cases are diagnosed at an early stage when surgery alone may be

adequate for cure.

Differences in epidemiology and prognosis suggest that two forms of endometrial cancer exist: type I endometrial carcinoma (80 percent) which is estrogen-related, usually is a low grade and favorable cell type tumor (endometrioid), and is associated with atypical endometrial hyperplasia. Common risk factors are obesity, nulliparity, estrogen excess, diabetes mellitus and hypertension. Type II endometrial cancer (20 percent), on the contrary, is unrelated to estrogen exposure or endometrial hyperplasia, and tends to be of higher grade and non-favorable cell types (clear cell and serous). Patients are often multiparous, older and are not obese, diabetic or hypertensive.4

Our current understanding of endometrial cancer risk factors only helps identify women at risk for type I endometrial cancer and are listed in Table 1. Other factors like nulliparity, diet, alcohol consumption and the age at which the patient experiences menarche and menopause, although implicated in the development of the disease, have been inconsistently determined

as independent risk factors.5–9 Factors like oral contraceptive pill use, progestin like hormonal contraception and smoking (increased liver metabolism of estrogen), are protective factors against endometrial cancer.10–12

Familial predisposition exists for certain types of endometrial cancer. Patients with hereditary nonpolyposis colorectal cancer syndrome 14-15(The Lynch syndrome II), in which the genetic hallmark is a germ-line mutation in the mismatch repair genes, are at increased risk of extra-colonic tumors, the most common of which are endometrial carcinomas (in up to 43 percent of females by age 70 in affected families). 13 Similarly, the breast cancer susceptibility gene BRCA1 may play a role in development of endometrial cancer. A multinational cohort and a prospective series have been associated with a small, but significantly increased risk of endometrial cancer for BRCA mutations carriers and carriers taking tamoxifen respectively.14-15 Further investigation on this regard is required.

Clinical presentation, diagnosis and screeningAbnormal uterine bleeding is the most common presentation and occurs in 90 percent of cases of endometrial cancer.16 Pre- and peri-menopausal events of abnormal bleeding should be evaluated for endometrial cancer, particularly if risk factors are present. The presence of benign appearing endometrial cells on cervical cancer screening is rarely associated with endometrial cancer; atypical endometrial cells, though, should alert the physician since the risk of cancer is higher when present. However, cervical cytology (Papanicolau smear) is not a screening method for endometrial cancer and it can miss 50 percent of all endometrial cancers. Furthermore, a negative cervical cytology does not rule out a cancer of the endometrium.

Endometrial cancer is a histological diagnosis, and even though non-invasive tools like ultrasonography and sonohysterography help triage women with abnormal uterine bleeding, tissue must always be obtained for diagnosis with a Pipelle, hysteroscopy and/or curettage.

General population screening in asymptomatic women for endometrial cancer is not warranted, except those with HNPCC whose risk of developing the disease is increased (40 to 60 percent). For women on tamoxifen there are no evidence-based guidelines for endometrial cancer screening; this is achieved based on symptom presentation and ultrasound findings.

Management and outcomesAccording to the joint International Federation of Gynecology and Obstetrics (FIGO)/American Joint Committee on Cancer (AJCC) classification system, endometrial cancer should be primarily surgically staged (Table 2). This surgical staging and several histologic factors obtained from it help guide the need for subsequent management with radiation and/or chemotherapy.

Endometrial cancer is usually diagnosed in the early stages (70 to 75 percent of cases are in stage I at diagnosis; 10 percent to 15 percent of cases are in stage II; 10 to 15 percent of cases are in stage III or IV). As a consequence, a better outcome is associated with it as opposed to other types of gynecological cancers, such as ovarian cancer. At the Avera Cancer Institute there seems to be a trend of increased numbers of stage III and IV and a decreased number of stage I cases at diagnosis in 2007 (Graph 2). This trend may be a reflection of the time period analyzed and reported in the current publication.

ENdOMETRIAL CANCER UpdATE ANd REvIEW

BY LuIS A. RojAS MD AnD SAMIR ABu-GHAzALEH MD, FACoG, FACS

Graph 1: The line defines median age of menopause in the united States, demonstrating a most common presentation of endometrial cancer in the postmenopausal state.

DR. LuIS RojAS DR. SAMIR ABu-GHAzALEH

Table1: Endometrial cancer risk factors

Risk factor Risk increase of endometrial cancer

unopposed estrogen therapy 2 – 10 times

Late menopause (after age 55) 2 times

nulliparity 2 times

Chronic anovulation 3 times

Obesity 2 – 4 times

Diabetes mellitus 2 times

Tamoxifen therapy 2/1000

hereditary nonpolyposis colorectal cancer 22 to 50 % lifetime risk increase

Table 2: Endometrial cancer staging.

fIGO TNM definitionstages Category

Tx Tumor can not be assessed

T0 no evidence of Tumor

Tis Carcinoma in situ (EIn)

I T1 Tumor Confined to the uterus IA T1a Limited to the endometrium IB T1b Invades < 50% of the myometrium IC T1c Invades > 50% of the myometrium

II T2 Extends to the cervix IIA T2a Only endocervical glands involved

IIB T2b Cervical stromal involvement

III T3 Local and/or regional spread IIIA T3a uterine serosa and/or adnexa and/or positive washings IIIB T3b vaginal involvement

IIIC n1 nodal metastasis to pelvic or perioartic region

IvA T4 Bladder or bowel mucosal involvement

IvB M1 Distant metastasis

~16~ ~17~

However, we can not disregard the possibility of this trend correlating with a delayed presentation of the patient to the physician in a primary care role, and as a consequence a delay in presentation for evaluation and management by the gynecologic oncologist. To clarify this detail, the authors are in the process of analyzing their experience in diagnosis and management of endometrial cancer at our institution in the past 25 years. A subsequent publication shall highlight interesting and revealing details.

The pattern of spread of endometrial cancer tends to be predictable and commonly will involve the nodal tissue in the pelvic and perioartic regions. Much less common and late presenting in the natural history of the disease are involvement of the lungs, inguinal and supraclavicular nodes, liver, peritoneal cavity, bone, brain and vagina. For this reason pre-staging evaluation should include a detailed history and physical examination by a gynecologic oncologist, including lymphovascular and neurologic evaluations. A complete blood count, serum chemistries as indicated by the patient’s age and medical co-morbidities and radiographic studies (chest X-ray always and computed tomography if extrapelvic disease suspected)17–18 should be evaluated. Measurement of the serum tumor marker CA 125 is a clinically useful test for predicting extrauterine spread of endometrial cancer, particularly in high risk histologic subtypes like grade 3, undifferentiated, clear cell and serous adenocarcinomas. However, this test is not sufficiently sensitive to take the place of surgical staging. This marker can aid in correctly identifying 75 to 87 percent of women requiring lymphadenectomy,19 but the optimal threshold has not been determined.20

The performance of this marker seems to be less accurate and more erratic in premenopausal patients.

Surgical staging should include a total hysterectomy (TH), bilateral salpingo-oophorectomy (BSO), cytologic examination of peritoneal washings/fluid, biopsy of any suspicious intraperitoneal or retroperitoneal lesions and retroperitoneal pelvic and periaortic lymph node dissections. Even though BSO excludes adnexal micrometastases and synchronous ovarian tumors and eliminates the estrogen source, some authors have suggested ovarian preservation in very selected and well-counseled young women at low risk of ovarian malignancy (e.g., no evidence of extrauterine disease, low stage, and low grade endometrial disease).21 The pelvic and perioartic lymphadenectomies should be “systematic and complete,” to include external, common and internal iliac, as well as obturator, pericaval and periaortic regions. Taking a few fatty tissue bundles and lymph nodes does not constitute a proper staging, will imply a suboptimal management of the patient and may compromise the patient’s outcome.

The current standard of care of performing this staging surgery is via laparotomy. However, observational studies and the Gynecologic Oncology Group phase III randomized clinical trial of laparoscopy versus laparotomy for endometrial cancer, for which preliminary results have been presented in the 2006 American Society of Clinical Oncology (ASCO) and Society of Gynecologic Oncology (SGO) annual meeting, demonstrate that minimally invasive surgery is an acceptable alternative to traditional laparotomy for women with early stage uterine cancer.22 Recently robotic assisted minimally invasive surgery has demonstrated further advantages, facilitating an expeditious and smoother recovery, with improved operative outcomes for women undergoing endometrial cancer staging.23

Randomized clinical trials comparing robotic-enhanced versus non-enhanced minimally invasive surgery are required to further validate the later observations.

In the past year, robotic technology was introduced at Avera McKennan Hospital & University Health Center, giving birth to our robotic surgery program. The success of this program is reflected in the 165 cases performed with robotic-enhanced minimally invasive surgery; moreover, it has come to revolutionize how we approach our endometrial cancer staging, since 50 percent of cases are done minimally invasively as opposed to less than 1 percent prior to the utilization of robotic assistance. Remarkable improvement in their overall recovery and return to functional life has also been well documented in this subgroup of patients.

Both the Society of Gynecologic Oncologists and the American College of Obstetricians and Gynecologists (ACOG) advise that women with endometrial cancer should undergo complete surgical staging as outlined above, and that the information obtained be used to select optimal postoperative treatment.

Prognosis is determined by disease stage and pathologic findings. An increased risk of extrauterine disease as well as recurrence after initial therapy have been demonstrated in patients with the following pathologic findings:24 serous, clear cell, or high-grade endometrioid histologies; myometrial invasion greater than 50 percent; lymphovascular space involvement; large tumor (>2.5 cm in diameter or filling the endometrial cavity), although the later is rendered a controversial finding.25

Prognosis and outcomes stratified by disease stage as indicated by the latest FIGO statistics, AJCC statistics and compared to Avera Cancer Institute statistics from 1998 to 2003 are depicted in Table 3 and Graphs 3-5.26 It is more than obvious that our outcomes are comparable to the Midwest, national and international outcomes. Our five year survival data may suggest better outcomes for stage II and III than the regional, national and international numbers. These numbers may need to be interpreted with caution, since they may be a reflection of the decreased number of patients reported at those stages and/or the time period of this analysis.

Graph 2: Endometrial cancer stage at diagnosis in 2007. Graph 3: Endometrial cancer survival by stage: Scope of the nation. Cases diagnosed from 1998 -2000, national Cancer Database

Graph 4: Endometrial cancer survival by stage: Scope of the Midwest. Cases diagnosed from 1998 – 2000, national Cancer Database

Graph 5: Endometrial cancer survival by stage: Avera Cancer Institute. Cases diagnosed from 2001 -2003*

* Data from 1998 – 2000 not complete for all stages.

Table 3: Endometrial cancer five year survival rates by stage: Comparison of international, national and regional outcomes with The Avera Cancer Institute.

stage/system fIGO Midwest National ACI

I 90.1 86.2 86.3 88.5

II 75.1 68.3 69.2 84.5

III 47.6 50.2 47.1 54.0

Iv 15.8 12.8 14.4 11.1

FIgO: International Federation of gynecology and Obstetrics.Midwest: data from 91 facilities in IA, KS, Mn, MO, nE, nD, SDnational: data from 1313 facilities in the nationACI: Avera Cancer Institute

~18~ ~19~

However, we can not disregard the possibility of this trend correlating with a delayed presentation of the patient to the physician in a primary care role, and as a consequence a delay in presentation for evaluation and management by the gynecologic oncologist. To clarify this detail, the authors are in the process of analyzing their experience in diagnosis and management of endometrial cancer at our institution in the past 25 years. A subsequent publication shall highlight interesting and revealing details.

The pattern of spread of endometrial cancer tends to be predictable and commonly will involve the nodal tissue in the pelvic and perioartic regions. Much less common and late presenting in the natural history of the disease are involvement of the lungs, inguinal and supraclavicular nodes, liver, peritoneal cavity, bone, brain and vagina. For this reason pre-staging evaluation should include a detailed history and physical examination by a gynecologic oncologist, including lymphovascular and neurologic evaluations. A complete blood count, serum chemistries as indicated by the patient’s age and medical co-morbidities and radiographic studies (chest X-ray always and computed tomography if extrapelvic disease suspected)17–18 should be evaluated. Measurement of the serum tumor marker CA 125 is a clinically useful test for predicting extrauterine spread of endometrial cancer, particularly in high risk histologic subtypes like grade 3, undifferentiated, clear cell and serous adenocarcinomas. However, this test is not sufficiently sensitive to take the place of surgical staging. This marker can aid in correctly identifying 75 to 87 percent of women requiring lymphadenectomy,19 but the optimal threshold has not been determined.20

The performance of this marker seems to be less accurate and more erratic in premenopausal patients.

Surgical staging should include a total hysterectomy (TH), bilateral salpingo-oophorectomy (BSO), cytologic examination of peritoneal washings/fluid, biopsy of any suspicious intraperitoneal or retroperitoneal lesions and retroperitoneal pelvic and periaortic lymph node dissections. Even though BSO excludes adnexal micrometastases and synchronous ovarian tumors and eliminates the estrogen source, some authors have suggested ovarian preservation in very selected and well-counseled young women at low risk of ovarian malignancy (e.g., no evidence of extrauterine disease, low stage, and low grade endometrial disease).21 The pelvic and perioartic lymphadenectomies should be “systematic and complete,” to include external, common and internal iliac, as well as obturator, pericaval and periaortic regions. Taking a few fatty tissue bundles and lymph nodes does not constitute a proper staging, will imply a suboptimal management of the patient and may compromise the patient’s outcome.

The current standard of care of performing this staging surgery is via laparotomy. However, observational studies and the Gynecologic Oncology Group phase III randomized clinical trial of laparoscopy versus laparotomy for endometrial cancer, for which preliminary results have been presented in the 2006 American Society of Clinical Oncology (ASCO) and Society of Gynecologic Oncology (SGO) annual meeting, demonstrate that minimally invasive surgery is an acceptable alternative to traditional laparotomy for women with early stage uterine cancer.22 Recently robotic assisted minimally invasive surgery has demonstrated further advantages, facilitating an expeditious and smoother recovery, with improved operative outcomes for women undergoing endometrial cancer staging.23

Randomized clinical trials comparing robotic-enhanced versus non-enhanced minimally invasive surgery are required to further validate the later observations.

In the past year, robotic technology was introduced at Avera McKennan Hospital & University Health Center, giving birth to our robotic surgery program. The success of this program is reflected in the 165 cases performed with robotic-enhanced minimally invasive surgery; moreover, it has come to revolutionize how we approach our endometrial cancer staging, since 50 percent of cases are done minimally invasively as opposed to less than 1 percent prior to the utilization of robotic assistance. Remarkable improvement in their overall recovery and return to functional life has also been well documented in this subgroup of patients.

Both the Society of Gynecologic Oncologists and the American College of Obstetricians and Gynecologists (ACOG) advise that women with endometrial cancer should undergo complete surgical staging as outlined above, and that the information obtained be used to select optimal postoperative treatment.

Prognosis is determined by disease stage and pathologic findings. An increased risk of extrauterine disease as well as recurrence after initial therapy have been demonstrated in patients with the following pathologic findings:24 serous, clear cell, or high-grade endometrioid histologies; myometrial invasion greater than 50 percent; lymphovascular space involvement; large tumor (>2.5 cm in diameter or filling the endometrial cavity), although the later is rendered a controversial finding.25

Prognosis and outcomes stratified by disease stage as indicated by the latest FIGO statistics, AJCC statistics and compared to Avera Cancer Institute statistics from 1998 to 2003 are depicted in Table 3 and Graphs 3-5.26 It is more than obvious that our outcomes are comparable to the Midwest, national and international outcomes. Our five year survival data may suggest better outcomes for stage II and III than the regional, national and international numbers. These numbers may need to be interpreted with caution, since they may be a reflection of the decreased number of patients reported at those stages and/or the time period of this analysis.

Graph 2: Endometrial cancer stage at diagnosis in 2007. Graph 3: Endometrial cancer survival by stage: Scope of the nation. Cases diagnosed from 1998 -2000, national Cancer Database

Graph 4: Endometrial cancer survival by stage: Scope of the Midwest. Cases diagnosed from 1998 – 2000, national Cancer Database

Graph 5: Endometrial cancer survival by stage: Avera Cancer Institute. Cases diagnosed from 2001 -2003*

* Data from 1998 – 2000 not complete for all stages.

Table 3: Endometrial cancer five year survival rates by stage: Comparison of international, national and regional outcomes with The Avera Cancer Institute.

stage/system fIGO Midwest National ACI

I 90.1 86.2 86.3 88.5

II 75.1 68.3 69.2 84.5

III 47.6 50.2 47.1 54.0

Iv 15.8 12.8 14.4 11.1

FIgO: International Federation of gynecology and Obstetrics.Midwest: data from 91 facilities in IA, KS, Mn, MO, nE, nD, SDnational: data from 1313 facilities in the nationACI: Avera Cancer Institute

~18~ ~19~

Other potential prognostic factors identified have been molecular marker expression of the tumors (p53, PTEN, ER and PR), age at diagnosis greater than 60 which is associated with higher rates of clinical and survival failure,27 and African-American origin which demonstrate consistently poorer outcomes than other ethnic groups.28

Adjuvant therapy depends directly on the aforementioned prognostic factors and risk of recurrence. Patients considered to be at low risk for recurrent disease are those with grade 1 or 2 histology and/or stages IA and IB. These patients are adequately treated with the above described surgery alone.29-30 Women at intermediate risk for recurrent disease are those with grade 1 or 2 and stage IC, or grade 3 and stage IA or IB tumors. These patients will require the above described surgery, with or without adjuvant radiation therapy. Chemotherapy, or a combination of both, has been proposed for selected cases. 30

Finally, patients considered at high risk for disease persistence or recurrence are those with grade 3 and stage IC, or stage IIA or greater stage disease, regardless of grade. These patients are properly managed and median survival benefit is seen with the above described surgery including resection of grossly enlarged nodes and maximal surgical cytoreduction (removal of all tumor larger than 2 cm) in selected patients.30-31 All patients should undergo adjuvant chemotherapy and/or radiation therapy depending on stage, since the outcome with surgery alone is poor.

Management of special populationsElderly patients with stage I disease and those with significant comorbidity with high surgical risk can be treated with primary RT. Disease-specific survival rates are similar or only slightly less than those of women undergoing recommended staging.30, 32

Vaginal or minimally invasive hysterectomy is another option for women whose cancers are felt clinically to be confined to the uterus.33

Women desiring future childbearing and early stage-low grade disease (stage I, grade 1) have occasionally been treated with progestin therapy.34 The response rates and survival of this approach are significantly less than with standard therapy35 and definitive surgical therapy is recommended after completion of childbearing.

SummaryEndometrial cancer is the most common gynecologic tract malignancy. An early diagnosis and overall favorable outcome are encountered, if timely referral to the gynecologic oncologist occurs. Our institutional experience at the Avera Cancer Institute, as represented above, seems to compare favorably to other regional, national and international institutions. The information discussed emphasizes the importance of appropriate systematic surgical staging and administration of a stage-adjusted treatment based on the state of the art and most current evidence.

References1. American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society; 2008.

2. Gallup, DG. Adenocarcinoma of the endometrium in women 40 years of age or younger. Obstet Gynecol 1984; 64:417.

3. South Dakota Department of Health and SEER Data registries 1990 – 2003.

4. Bokhman, JV. Two pathogenetic types of endometrial carcinoma. Gynecol Oncol 1983; 15:10.

5. Potischman, N, Swanson, CA, Brinton, LA, et al. Dietary associations in a case-control study of endometrial cancer. Cancer Causes Control 1993; 4:239.

6. Horn-Ross, PL. Phytoestrogen intake and endometrial cancer risk. J Natl Cancer Inst 2003; 95:1158.

7. Gapstur, SM,. Alcohol consumption and postmenopausal endometrial cancer: results from the Iowa Women’s Health Study. Cancer Causes Control 1993; 4:323.

8. Loerbroks, A. Alcohol consumption, cigarette smoking, and endometrial cancer risk: results from the Netherlands Cohort Study. Cancer Causes Control 2007; 18:551.

9. La Vecchia, C. Risk factors for endometrial cancer at different ages. J Natl Cancer Inst 1984; 73:667.

10. Anonymous 1987. Combination oral contraceptive use and the risk of endometrial cancer. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. JAMA 1987; 257:796

11. Cullins, VE. Noncontraceptive benefits and therapeutic uses of depot medroxyprogesterone acetate. J Reprod Med 1996; 41:428.

12. Viswanathan, AN. Smoking and the risk of endometrial cancer: results from the Nurses’ Health Study. Int J Cancer 2005; 114:996.

13. Aarnio, M. Lifetime risk of different cancers in hereditary non-polyposis colorectal cancer (HNPCC) syndrome. Int J Cancer 1995; 64:430.

14. Thompson, D. Cancer Incidence in BRCA1 mutation carriers. J Natl Cancer Inst 2002; 94:1358.

15. Finch, A. The risk of endometrial cancer in women with BRCA1 and BRCA2 mutations. A prospective study. Gynecol Oncol 2007; 104:7.

16. ACOG practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005; 106:413.

17. Connor, JP. Computed tomography in endometrial cancer. Obstet Gynecol 2000; 95:692.

18. Zerbe, MJ. Inability of preoperative computed tomography scans to accurately predict the extent of myometrial invasion and extracorporal spread in endometrial cancer. Gynecol Oncol 2000; 78:67.

19. Dotters, DJ. Preoperative CA 125 in endometrial cancer: is it useful?. Am J Obstet Gynecol 2000; 182:1328.

20. Hsieh, CH. Can a Preoperative CA 125 Level Be a Criterion for Full Pelvic Lymphadenectomy in Surgical Staging of Endometrial Cancer?. Gynecol Oncol 2002; 86:28.

21. Lee, TS. Feasibility of ovarian preservation in patients with early stage endometrial carcinoma. Gynecol Oncol 2007; 104:52.

22. Kalogiannidis, I. Laparoscopy-assisted vaginal hysterectomy compared with abdominal hysterectomy in clinical stage I endometrial cancer: safety, recurrence, and long-term outcome. Am J Obstet Gynecol 2007; 196:248.

23. Boggess, JF. Robotic Assistance Improves Minimally Invasive Surgery For Endometrial Cancer. Poster presented at SGO 2007. Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill.

24. Morrow, CP. Relationship between surgical-pathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol 1991; 40:55.

25. Shah, C. Does size matter? Tumor size and morphology as predictors of nodal status and recurrence in endometrial cancer. Gynecol Oncol 2005; 99:564.

26. Creasman, WT. Carcinoma of the corpus uteri. J Epid Biostat 2001; 6:45.

27. Creutzberg, CL. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet 2000; 355:1404.

28. Hicks, ML. The National Cancer Data Base report on endometrial carcinoma in African-American women. Cancer 1998; 83:2629.

29. Roper, B. Ten-year data on 138 patients with endometrial carcinoma and postoperative vaginal brachytherapy alone: no need for external-beam radiotherapy in low and intermediate risk patients. Gynecol Oncol 2007; 107:541.

30. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology available at www.nccn.org/professionals/physician_gls/default.asp

31. Lambrou, NC. Optimal surgical cytoreduction in patients with Stage III and Stage IV endometrial carcinoma: a study of morbidity and survival. Gynecol Oncol 2004; 93:653.

32. Grigsby, PW. Medically inoperable stage I adenocarcinoma of the endometrium treated with radiotherapy alone. Int J Radiat Oncol Biol Phys 1987; 13:483

33. Susini, T. Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly. Gynecol Oncol 2005; 96:362

34. Ramirez, PT. Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review. Gynecol Oncol 2004; 95:133

35. Ushijima, K. Multicenter phase II study of fertility-sparing treatment with medroxyprogesterone acetate for endometrial carcinoma and atypical hyperplasia in young women. J Clin Oncol 2007; 25:2798

~20~ ~21~

Other potential prognostic factors identified have been molecular marker expression of the tumors (p53, PTEN, ER and PR), age at diagnosis greater than 60 which is associated with higher rates of clinical and survival failure,27 and African-American origin which demonstrate consistently poorer outcomes than other ethnic groups.28

Adjuvant therapy depends directly on the aforementioned prognostic factors and risk of recurrence. Patients considered to be at low risk for recurrent disease are those with grade 1 or 2 histology and/or stages IA and IB. These patients are adequately treated with the above described surgery alone.29-30 Women at intermediate risk for recurrent disease are those with grade 1 or 2 and stage IC, or grade 3 and stage IA or IB tumors. These patients will require the above described surgery, with or without adjuvant radiation therapy. Chemotherapy, or a combination of both, has been proposed for selected cases. 30

Finally, patients considered at high risk for disease persistence or recurrence are those with grade 3 and stage IC, or stage IIA or greater stage disease, regardless of grade. These patients are properly managed and median survival benefit is seen with the above described surgery including resection of grossly enlarged nodes and maximal surgical cytoreduction (removal of all tumor larger than 2 cm) in selected patients.30-31 All patients should undergo adjuvant chemotherapy and/or radiation therapy depending on stage, since the outcome with surgery alone is poor.

Management of special populationsElderly patients with stage I disease and those with significant comorbidity with high surgical risk can be treated with primary RT. Disease-specific survival rates are similar or only slightly less than those of women undergoing recommended staging.30, 32

Vaginal or minimally invasive hysterectomy is another option for women whose cancers are felt clinically to be confined to the uterus.33

Women desiring future childbearing and early stage-low grade disease (stage I, grade 1) have occasionally been treated with progestin therapy.34 The response rates and survival of this approach are significantly less than with standard therapy35 and definitive surgical therapy is recommended after completion of childbearing.

SummaryEndometrial cancer is the most common gynecologic tract malignancy. An early diagnosis and overall favorable outcome are encountered, if timely referral to the gynecologic oncologist occurs. Our institutional experience at the Avera Cancer Institute, as represented above, seems to compare favorably to other regional, national and international institutions. The information discussed emphasizes the importance of appropriate systematic surgical staging and administration of a stage-adjusted treatment based on the state of the art and most current evidence.

References1. American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society; 2008.

2. Gallup, DG. Adenocarcinoma of the endometrium in women 40 years of age or younger. Obstet Gynecol 1984; 64:417.

3. South Dakota Department of Health and SEER Data registries 1990 – 2003.

4. Bokhman, JV. Two pathogenetic types of endometrial carcinoma. Gynecol Oncol 1983; 15:10.

5. Potischman, N, Swanson, CA, Brinton, LA, et al. Dietary associations in a case-control study of endometrial cancer. Cancer Causes Control 1993; 4:239.

6. Horn-Ross, PL. Phytoestrogen intake and endometrial cancer risk. J Natl Cancer Inst 2003; 95:1158.

7. Gapstur, SM,. Alcohol consumption and postmenopausal endometrial cancer: results from the Iowa Women’s Health Study. Cancer Causes Control 1993; 4:323.

8. Loerbroks, A. Alcohol consumption, cigarette smoking, and endometrial cancer risk: results from the Netherlands Cohort Study. Cancer Causes Control 2007; 18:551.

9. La Vecchia, C. Risk factors for endometrial cancer at different ages. J Natl Cancer Inst 1984; 73:667.

10. Anonymous 1987. Combination oral contraceptive use and the risk of endometrial cancer. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. JAMA 1987; 257:796

11. Cullins, VE. Noncontraceptive benefits and therapeutic uses of depot medroxyprogesterone acetate. J Reprod Med 1996; 41:428.

12. Viswanathan, AN. Smoking and the risk of endometrial cancer: results from the Nurses’ Health Study. Int J Cancer 2005; 114:996.

13. Aarnio, M. Lifetime risk of different cancers in hereditary non-polyposis colorectal cancer (HNPCC) syndrome. Int J Cancer 1995; 64:430.

14. Thompson, D. Cancer Incidence in BRCA1 mutation carriers. J Natl Cancer Inst 2002; 94:1358.

15. Finch, A. The risk of endometrial cancer in women with BRCA1 and BRCA2 mutations. A prospective study. Gynecol Oncol 2007; 104:7.

16. ACOG practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005; 106:413.

17. Connor, JP. Computed tomography in endometrial cancer. Obstet Gynecol 2000; 95:692.

18. Zerbe, MJ. Inability of preoperative computed tomography scans to accurately predict the extent of myometrial invasion and extracorporal spread in endometrial cancer. Gynecol Oncol 2000; 78:67.

19. Dotters, DJ. Preoperative CA 125 in endometrial cancer: is it useful?. Am J Obstet Gynecol 2000; 182:1328.

20. Hsieh, CH. Can a Preoperative CA 125 Level Be a Criterion for Full Pelvic Lymphadenectomy in Surgical Staging of Endometrial Cancer?. Gynecol Oncol 2002; 86:28.

21. Lee, TS. Feasibility of ovarian preservation in patients with early stage endometrial carcinoma. Gynecol Oncol 2007; 104:52.

22. Kalogiannidis, I. Laparoscopy-assisted vaginal hysterectomy compared with abdominal hysterectomy in clinical stage I endometrial cancer: safety, recurrence, and long-term outcome. Am J Obstet Gynecol 2007; 196:248.

23. Boggess, JF. Robotic Assistance Improves Minimally Invasive Surgery For Endometrial Cancer. Poster presented at SGO 2007. Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill.

24. Morrow, CP. Relationship between surgical-pathological risk factors and outcome in clinical stage I and II carcinoma of the endometrium: a Gynecologic Oncology Group study. Gynecol Oncol 1991; 40:55.

25. Shah, C. Does size matter? Tumor size and morphology as predictors of nodal status and recurrence in endometrial cancer. Gynecol Oncol 2005; 99:564.

26. Creasman, WT. Carcinoma of the corpus uteri. J Epid Biostat 2001; 6:45.

27. Creutzberg, CL. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet 2000; 355:1404.

28. Hicks, ML. The National Cancer Data Base report on endometrial carcinoma in African-American women. Cancer 1998; 83:2629.

29. Roper, B. Ten-year data on 138 patients with endometrial carcinoma and postoperative vaginal brachytherapy alone: no need for external-beam radiotherapy in low and intermediate risk patients. Gynecol Oncol 2007; 107:541.

30. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology available at www.nccn.org/professionals/physician_gls/default.asp

31. Lambrou, NC. Optimal surgical cytoreduction in patients with Stage III and Stage IV endometrial carcinoma: a study of morbidity and survival. Gynecol Oncol 2004; 93:653.

32. Grigsby, PW. Medically inoperable stage I adenocarcinoma of the endometrium treated with radiotherapy alone. Int J Radiat Oncol Biol Phys 1987; 13:483

33. Susini, T. Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly. Gynecol Oncol 2005; 96:362

34. Ramirez, PT. Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review. Gynecol Oncol 2004; 95:133

35. Ushijima, K. Multicenter phase II study of fertility-sparing treatment with medroxyprogesterone acetate for endometrial carcinoma and atypical hyperplasia in young women. J Clin Oncol 2007; 25:2798

~20~ ~21~

CANCER REGIsTRYAvERA MCKEnnAn hOSPITAL & unIvERSITY hEALTh CEnTER

2007 sUMMARY bY bOdY sYsTEM ANd sEx

primary site Total % Male % female %

ORAL CAvITY & phARYNx 12 0.9% 11 2.0% 1 0.1%

dIGEsTIvE sYsTEM 252 18.8% 132 24.1% 120 15.1%

Esophagus 17 1.3% 12 2.2% 5 0.6%

Stomach 14 1.0% 9 1.6% 5 0.6%

Small Intestine 3 0.2% 2 0.4% 1 0.1%

Colon 94 7.0% 45 8.2% 49 6.1%

Rectum and Rectosigmoid 34 2.5% 24 4.4% 10 1.3%

Anus, Anal Canal and Anorectum 2 0.1% 1 0.2% 1 0.1%

Liver and Intrahepatic Bile Duct 7 0.5% 4 0.7% 3 0.4%

gallbladder 5 0.4% 1 0.2% 4 0.5%

Other Biliary 7 0.5% 3 0.5% 4 0.5%

Pancreas 59 4.4% 28 5.1% 31 3.9%

Retroperitoneum 3 0.2% 1 0.2% 2 0.3%

Peritoneum, Omentum and Mesentery 5 0.4% 0 0.0% 5 0.6%

Other Digestive Organs 2 0.1% 2 0.4% 0 0.0%

REspIRATORY sYsTEM-Lung, Larynx, Trachea 174 12.9% 91 16.6% 83 10.4%

bONEs & JOINTs 4 0.3% 3 0.5% 1 0.1%

sOfT TIssUE 4 0.3% 3 0.5% 1 0.1%

skIN - MELANOMA 47 3.5% 29 5.3% 18 2.3%

bREAsT 234 17.4% 2 0.4% 232 29.1%

fEMALE GENITAL sYsTEM 118 8.8% 0 0.0% 118 14.8%

Cervix uteri 16 1.2% 0 0.0% 16 2.0%

Corpus and uterus, nOS 63 4.7% 0 0.0% 63 7.9%

Ovary 24 1.8% 0 0.0% 24 3.0%

vulva 12 0.9% 0 0.0% 12 1.5%

Other Female genital Organs 3 0.2% 0 0.0% 3 0.3%

MALE GENITAL sYsTEM 105 7.7% 105 19.0% 0 0.0%

Prostate 99 7.4% 99 18.1% 0 0.0%

Testis 5 0.4% 5 0.7% 0 0.0%

Penis 1 0.1% 1 0.2% 0 0.0%

URINARY sYsTEM 74 5.5% 41 7.5% 33 4.1%

urinary Bladder 25 1.9% 20 3.7% 5 0.6%

Kidney and Renal Pelvis 47 3.5% 21 3.8% 26 3.3%

ureter 2 0.1% 0 0.0% 2 0.3%

W h A T A R E T h E B E n E F I T S O F B E I n g A CoC-AppROvEd CANCER pROGRAM?for the patient and community,our standards ensure: n Quality care close to home n Comprehensive care offering a complete range

of state-of-the-art services and equipment n A multidisciplinary team approach to coordinate

the best treatment options available n Information about ongoing cancer clinical trials

and new treatment options n Access to cancer-related education and support

for the facility and medical staff, our approval program offers:

n A model for organizing and managing your cancer program to assure multidisciplinary, integrated and comprehensive oncology services

n Recognition by other national health care organizations, including Joint Commission, as having established performance measures for high quality cancer care

n The ability to meet demands for oncology data from clinicians and other health care professionals, third-party payors and managed care organizations and the public because of the CoC requirement for a cancer registry.

n Participation in a network of quality cancer programs that provide care to 80 percent of newly-diagnosed cancer patients

n Free marketing and national public exposure by partnering with the CoC and American Cancer Society (ACS) in the Facility Information Profile System (FIPS) – an information sharing effort of resources and services and cancer experience for the ACS national Call Center and web site

n An approved Cancer Program Performance Report that enables a facility to compare its standard ratings with other approved programs in the state and approval award category to identify quality improvement initiatives

n Participation in the national Cancer Data Base (nCDB), a nationwide oncology outcomes database for more than 1,400 hospitals

n Immediate feedback on the quality of data submissions to the nCDB based on national standardized data edit reports

n Access to benchmark reports containing national aggregate data and individual facility data to assess patterns of care and outcomes relative to national norms

n Participation in special studies for the ad hoc collection of specific data to address important cancer problems

www.facs.org

(312) 202-5085

~22~ ~23~

CANCER REGIsTRYAvERA MCKEnnAn hOSPITAL & unIvERSITY hEALTh CEnTER

2007 sUMMARY bY bOdY sYsTEM ANd sEx (CONT.)

primary site Total % Male % female %

bRAIN ANd OThER NERvOUs sYsTEM 66 4.9% 23 4.2% 43 5.4%

ENdOCRINE sYsTEM 38 2.8% 10 1.8% 28 3.5%

Thyroid 31 2.3% 6 1.1% 25 3.1%

Other Endocrine (including Thymus) 7 0.5% 4 0.7% 3 0.4%

LYMphOMAs 75 5.6% 34 6.2% 41 5.1%

hodgkin Lymphoma 9 0.7% 4 0.7% 5 0.6%

non-hodgkin Lymphoma 66 4.9% 30 5.5% 36 4.5%

MULTIpLE MYELOMA 20 1.5% 9 1.6% 11 1.4%

LEUkEMIAs 45 3.3% 16 2.9% 29 3.6%

Lymphocytic Leukemias 27 2.0% 12 2.2% 15 1.9%

Myeloid and Monocytic Leukemias 18 1.3% 4 0.7% 14 1.8%

MEsOThELIOMA 4 0.3% 2 0.4% 2 0.3%

kApOsI sARCOMA 1 0.1% 0 0.0% 1 0.1%

MIsCELLANEOUs 72 5.4% 37 6.8% 35 4.4%

TOTAL 1,345 548 797

Males females 548 797

Oral Cavity and Pharynx - 11 (2%) Thyroid - 25 (3%) Lung and Bronchus - 89 (16%) Lung and Bronchus - 83 (10%) Breast - 232 (29%) Pancreas - 28 (5%) Kidney and Renal Pelvis - 21 (4%) Kidney and Renal Pelvis - 26 (3%) urinary Bladder - 20 (4%) Ovary - 24 (3%) Colon and Rectum - 69 (13%) uterine Corpus - 63 (8%) Prostate - 99 (18%) Colon and Rectum - 59 (7%) non-hodgkin Lymphoma - 30 (5%) non-hodgkin Lymphoma - 36 (5%) Melanoma of the Skin - 29 (5%) Melanoma of the Skin - 18 (2%) Leukemia - 16 (3%) Leukemia - 29 (4%) All Other Sites - 135 (25%) All Other Sites - 202 (25%)

Images reprinted by the permission of the American Cancer Society, Inc. from www.cancer.org. All rights reserved.

~24~ ~25~

*

*American Joint Committee on Cancer

CANCER REGIsTRYAvERA MCKEnnAn hOSPITAL & unIvERSITY hEALTh CEnTER

2007 sUMMARY bY bOdY sYsTEM ANd sEx

primary site Total % Male % female %

ORAL CAvITY & phARYNx 12 0.9% 11 2.0% 1 0.1%

dIGEsTIvE sYsTEM 252 18.8% 132 24.1% 120 15.1%

Esophagus 17 1.3% 12 2.2% 5 0.6%

Stomach 14 1.0% 9 1.6% 5 0.6%

Small Intestine 3 0.2% 2 0.4% 1 0.1%

Colon 94 7.0% 45 8.2% 49 6.1%

Rectum and Rectosigmoid 34 2.5% 24 4.4% 10 1.3%

Anus, Anal Canal and Anorectum 2 0.1% 1 0.2% 1 0.1%

Liver and Intrahepatic Bile Duct 7 0.5% 4 0.7% 3 0.4%

gallbladder 5 0.4% 1 0.2% 4 0.5%

Other Biliary 7 0.5% 3 0.5% 4 0.5%

Pancreas 59 4.4% 28 5.1% 31 3.9%

Retroperitoneum 3 0.2% 1 0.2% 2 0.3%

Peritoneum, Omentum and Mesentery 5 0.4% 0 0.0% 5 0.6%

Other Digestive Organs 2 0.1% 2 0.4% 0 0.0%

REspIRATORY sYsTEM-Lung, Larynx, Trachea 174 12.9% 91 16.6% 83 10.4%

bONEs & JOINTs 4 0.3% 3 0.5% 1 0.1%

sOfT TIssUE 4 0.3% 3 0.5% 1 0.1%

skIN - MELANOMA 47 3.5% 29 5.3% 18 2.3%

bREAsT 234 17.4% 2 0.4% 232 29.1%

fEMALE GENITAL sYsTEM 118 8.8% 0 0.0% 118 14.8%

Cervix uteri 16 1.2% 0 0.0% 16 2.0%

Corpus and uterus, nOS 63 4.7% 0 0.0% 63 7.9%

Ovary 24 1.8% 0 0.0% 24 3.0%

vulva 12 0.9% 0 0.0% 12 1.5%

Other Female genital Organs 3 0.2% 0 0.0% 3 0.3%

MALE GENITAL sYsTEM 105 7.7% 105 19.0% 0 0.0%

Prostate 99 7.4% 99 18.1% 0 0.0%

Testis 5 0.4% 5 0.7% 0 0.0%

Penis 1 0.1% 1 0.2% 0 0.0%

URINARY sYsTEM 74 5.5% 41 7.5% 33 4.1%

urinary Bladder 25 1.9% 20 3.7% 5 0.6%

Kidney and Renal Pelvis 47 3.5% 21 3.8% 26 3.3%

ureter 2 0.1% 0 0.0% 2 0.3%

W h A T A R E T h E B E n E F I T S O F B E I n g A CoC-AppROvEd CANCER pROGRAM?for the patient and community,our standards ensure: n Quality care close to home n Comprehensive care offering a complete range

of state-of-the-art services and equipment n A multidisciplinary team approach to coordinate

the best treatment options available n Information about ongoing cancer clinical trials

and new treatment options n Access to cancer-related education and support

for the facility and medical staff, our approval program offers:

n A model for organizing and managing your cancer program to assure multidisciplinary, integrated and comprehensive oncology services

n Recognition by other national health care organizations, including Joint Commission, as having established performance measures for high quality cancer care

n The ability to meet demands for oncology data from clinicians and other health care professionals, third-party payors and managed care organizations and the public because of the CoC requirement for a cancer registry.

n Participation in a network of quality cancer programs that provide care to 80 percent of newly-diagnosed cancer patients

n Free marketing and national public exposure by partnering with the CoC and American Cancer Society (ACS) in the Facility Information Profile System (FIPS) – an information sharing effort of resources and services and cancer experience for the ACS national Call Center and web site

n An approved Cancer Program Performance Report that enables a facility to compare its standard ratings with other approved programs in the state and approval award category to identify quality improvement initiatives

n Participation in the national Cancer Data Base (nCDB), a nationwide oncology outcomes database for more than 1,400 hospitals

n Immediate feedback on the quality of data submissions to the nCDB based on national standardized data edit reports

n Access to benchmark reports containing national aggregate data and individual facility data to assess patterns of care and outcomes relative to national norms

n Participation in special studies for the ad hoc collection of specific data to address important cancer problems

www.facs.org

(312) 202-5085

~22~ ~23~

CANCER REGIsTRYAvERA MCKEnnAn hOSPITAL & unIvERSITY hEALTh CEnTER

2007 sUMMARY bY bOdY sYsTEM ANd sEx (CONT.)

primary site Total % Male % female %

bRAIN ANd OThER NERvOUs sYsTEM 66 4.9% 23 4.2% 43 5.4%

ENdOCRINE sYsTEM 38 2.8% 10 1.8% 28 3.5%

Thyroid 31 2.3% 6 1.1% 25 3.1%

Other Endocrine (including Thymus) 7 0.5% 4 0.7% 3 0.4%

LYMphOMAs 75 5.6% 34 6.2% 41 5.1%

hodgkin Lymphoma 9 0.7% 4 0.7% 5 0.6%

non-hodgkin Lymphoma 66 4.9% 30 5.5% 36 4.5%

MULTIpLE MYELOMA 20 1.5% 9 1.6% 11 1.4%

LEUkEMIAs 45 3.3% 16 2.9% 29 3.6%

Lymphocytic Leukemias 27 2.0% 12 2.2% 15 1.9%

Myeloid and Monocytic Leukemias 18 1.3% 4 0.7% 14 1.8%

MEsOThELIOMA 4 0.3% 2 0.4% 2 0.3%

kApOsI sARCOMA 1 0.1% 0 0.0% 1 0.1%

MIsCELLANEOUs 72 5.4% 37 6.8% 35 4.4%

TOTAL 1,345 548 797

Males females 548 797

Oral Cavity and Pharynx - 11 (2%) Thyroid - 25 (3%) Lung and Bronchus - 89 (16%) Lung and Bronchus - 83 (10%) Breast - 232 (29%) Pancreas - 28 (5%) Kidney and Renal Pelvis - 21 (4%) Kidney and Renal Pelvis - 26 (3%) urinary Bladder - 20 (4%) Ovary - 24 (3%) Colon and Rectum - 69 (13%) uterine Corpus - 63 (8%) Prostate - 99 (18%) Colon and Rectum - 59 (7%) non-hodgkin Lymphoma - 30 (5%) non-hodgkin Lymphoma - 36 (5%) Melanoma of the Skin - 29 (5%) Melanoma of the Skin - 18 (2%) Leukemia - 16 (3%) Leukemia - 29 (4%) All Other Sites - 135 (25%) All Other Sites - 202 (25%)

Images reprinted by the permission of the American Cancer Society, Inc. from www.cancer.org. All rights reserved.

~24~ ~25~

*

*American Joint Committee on Cancer