Understanding Cancer Mini Med School

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The Advisory Board Company

Washington, D.C.

Presented by

Fabienne Moore, MD MPH

Senior Director, Talent Development

February 22, 2011

Mini Med School

• Facilitated Training Opportunities

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Cardiovascular

Care

TBD

Cancer

Care

Fabienne Moore, MD MPH

Today’s Module

Trauma

Care

Sean Benoit, MD

Roadmap for Discussion

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I. Cancer Biology

II. Diagnosing Cancer

III. Cancer Treatments

IV. Key Strategic Concerns

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I

Cancer Biology

A Cell that Goes Wrong

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Cancer Biology

Causes of Cancer

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Cancer Genetics

Familial (inherited)- Genetic Multi-factorial – Environmental,

Lifestyle

VS.

It only takes one mutation….

• BRCA gene mutations

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Cancer Biology

Basic Pathology

Heterogeneity of Cancer

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Tumor Sites

Lung & Bronchus

MelanomaHead & Neck

Pancreas

Breast (SEM)

Hematologic vs Solid Cancers

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Hematological Cancer

(e.g.. Leukemia)Solid Cancer (e.g. Soft

Tissue Sarcoma)

When is it Cancer?

• Epithelial cells (left) are tightly interconnected in sheets by numerous cell-cell interactions; their organization is determined by the basement membrane (lower left).

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Tumor Classification

Benign

Not invading surrounding

tissue or spreading to other

parts of the body.; may grow

but it stays put (in the same

place).

Malignant

Having the ability to invade

surrounding tissue and spread to

other locations throughout the

body

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Size Doesn’t Matter

Benign vs. Malignant Masses

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Benign Mass: Smooth-edged,

well-circumscribed,

encapsulated, homogenous

Malignant Tumor: invasive,

shaggy, ill-defined borders,

heterogenoous

Under the Microscope…

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Normal Kidney Benign Tumor

Renal Cell Carcinoma

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Stage 1: T1 N0 M0; T2 N0 M0 - Cancer has begun to spread, but is still in the inner lining

Stage 2: T3 N0 M0; T4 N0 M0 - Cancer has spread to other organs near the colon or rectum. It has not reached lymph nodes.

Stage 3: Any T, N1-2, M0 - Cancer has spread to lymph nodes, but has not been carried to distant parts of the body

Stage 4: Any T, any N, M1 - Cancer has been carried through the lymph system to distant parts of the body. The most likely organs to

experience metastasis from colorectal cancer are the lungs and liver.

Tumor Classification

After Biopsy, the tumor may be

more accurately classified in the

following method:

By Tumor, which describes the

invasion of cancer cells into an

immediately surrounding the

tumor site. Graded T to T4

By Lymph Node involvement.

Graded NX to N1

By Metastasis, or distal spread

of cancer cells to other tissues.

Graded PM1c-M1c

By Surgical Margins:

Graded as R

Staging: How Far Has it

Progressed?

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Metastases Revisited

Local Cancer (e.g.

Stomach Cancer)

VS.

Metastases

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II

Diagnosing Cancer

The Big Four

Tumor SiteIncidence

Rate*% of Cancer

Mortality Incidence Rate% of Cancer

Mortality

Breast -- -- 120.4 15%

Lung 80.5 31% 54.5 26%

Prostate 156.9 10% -- --

Colorectal 52.7 8% 39.7 10%

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U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based

Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National

Cancer Institute; 2010. Available at: www.cdc.gov/uscs.

2007 Estimated New Cases & Cancer Deaths in US

The Rest, 2007 Estimated Deaths

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Men

Pancreas 6%

Leukemia 4%

Non-Hodgkin Lymphoma 3%

Esophagus 4%

Liver and intrahepatic bile duct 4%

Kidney 3%

Other sites 27%

Women

Ovary 6%

Pancreas 6%

Leukemia 4%

Non-Hodgkin Lymphoma 3%

Uterine corpus 3%

Multiple myeloma 2%

Brain/nervous system 2%

Other sites 23%

Source: American Cancer Society, 2007.

Pediatric Epidemiology

Site Male Female Total

Leukemia 5.3 4.5 4.9

Brain 3.4 3.1 3.2

Non-Hodgkinslymphoma

1.1 0.6 0.9

Kidney & renal pelvis

0.8 0.8 0.8

Soft tissue 1.0 1.1 1.0

All sites 15.8 14.0 14.9

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Cancer Incidence Rates* in Children, 0-14 Years

*per 100,000 age-adjusted to the 2000 US standard population

Source: American Cancer Society, 2007.

Pediatric Epidemiology

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Trends in Survival, Children 0-14 Years

Age

0-4

5-9

10-14

Year of Diagnosis 5 Year Relative Survival Rates

57.31974-76

1992-99 80.2

1974-76

1992-99

1974-76

1992-99

58.5

78.3

58.9

79.9

Source: American Cancer Society, 2007.

How Is Cancer Diagnosed?

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Diagnosis: The process of identifying a disease based on signs

and symptoms

Signs Symptoms

•Shortness of

breath

•Chest pain

•Loss of appetite

•Inflammation of

lungs (pneumonia)

•Wheezing

•Hemoptysis

(bloody, coughed-

up sputum)

•Weight Loss

•Cough

Preemptively Seeking Out Disease

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Mammography: Low dose x-ray system used to screen breasts

for early signs of cancer

Screening Technologies

PSA Test: Blood test which measures the amount

of prostate-specific antigen in the blood

Colonoscopy: visual inspection of the colon to screen for

polyps or other masses

The Next Screening Frontier

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Virtual Colonoscopy: Also known as CT colonography, uses

computed tomography (CT scan) to generate unique 2- and 3-D

images of the colon to identify cancerous polyps

Breast MRI: high-resolution MRI provides increased sensitivity

for breast cancer screening in a radiation-free screening modality

Ruling In (or Out) Cancer

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Diagnostic Technologies

Biopsy PET

Positron emission

tomography (PET) is

used to detect

radiation from

emission of positrons

in the body. Most

commonly used to

detect cancer or

examine effects of

cancer therapy on the

body

A biopsy is a

procedure in which a

cylinder of tissue is

removed from the

body and tested under

a microscope for signs

of cancer

Types of Oncologists

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Medical Oncology

Radiation Oncology

Interventional

Oncology

Cancer Physicians

Internists, certified by the American Board

of internal medicine, who use medical and

chemotherapeutic means to treat cancer

Radiation oncologists, certified by the

American College of Radiology, specialize in

radiation treatment of cancers

Surgical oncologists, certified by the

American Board of Surgery, are trained in

several types of surgical treatments,

including biopsy, tumor staging, and tumor

removal

Surgical Oncology

Interventional Radiologists—specializing in

image guided, minimally invasive

interventions—with a distinct focus on

treating cancer cases

Other Important Physicians

• Diagnosis and Treatment

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Radiologists Pathologists Other Specialists

• Thoracic Surgeons

• Urologists

• Pulmonologists

• Primary Care

Physicians

• Physiatrists

• Almost every doctor

deals with cancer

Tumor Boards the Gold Standard• Multidisciplinary approach brings all clinicians to the table

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Hepatocellular

Carcinoma

PatientRadiation

Oncologist

Interventional

Radiologist Radiologist

Transplant

Surgeon

Primary Care

Physician

Transplant

Coordinator

Medical

Oncologist

Psychologist

Hepatobiliary

Surgeon

Introducing Gary Hetch

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Case Study

Gary Hetch, 55• Database administrator at small, IT firm in FL

• Wife, Brenda, and three children, 28, 23, and 18

• Makes appointment at his physician’s office after

experiencing blood in urine and pain/stiffness in his

back and hips

• Family history: Mother died of breast cancer at

age 76

• No previous screening tests

Was Gary at risk?

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Environmental

FactorsGenetic Factors

•Long-time follower of

Atkin’s Diet, high-

protien, high-fat

•Selenium-, lycopene-,

and fiber-deficient diet

(Mom would have

disapproved)

•IT: sedentary job

•Family history of breast

cancer (mother and

grandmother)

Gary’s path to the hospital

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Doctor’s Office Specialist’s Office Hospital

Gary shows up

at his doctor’s

office,

complaining of

blood in urine

and stiff hip/back

Gary is referred

to urologist for

additional

testing, PSA

elevated

Gary’s urologist

schedules

prostate biopsy

at hospital

Biopsy confirms

prostate cancer

Staging and Treatment

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Dr. Feretti

Radiation Oncologist

• Imaging tests reveal metastases to spine, confirming

stage IV prostate cancer

• Gary works with Feretti, radiation oncologist, to establish

course of care

•5 treatments per week for 7 weeks at hospital’s

outpatient radiology center

•Post-treatment, Dr. Feretti, Gary, and his primary care

physician will work together to monitor progress with PSA

testing

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III

Cancer Treatments

Wide Range of Treatment Options

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Oncology Treatment Technology Benchmarking by Sub-Service Line

Sub-Service

Line

Standard Offering Advanced Offering Progressive Edge

Radiation

Oncology

Interventional-

Surgical

Oncology

Medical

Oncology

Diagnostic

Imaging

IMRT IGRT

HDR

BrachytherapyLDR

Brachytherapy

Extracranial

SRSProton

Beam

Therapy3D-CRT

Cryoablation

Robotic

Surgery

RFA

VMAT

PET/CT1.5T Fixed-

Site MRI 7T MRI

3T MRI

SPECT/CT

Film MammographyFull-Field

Digital MammographyBreast

Tomosynthesis

Digital X-Ray

Tomosynthesis

Ultrasound

4-Slice

CT

16-Slice CT 64-Slice

CT

Next-Generation CT

Intracranial

SRS IORT

2D-CRT

Cryoablation

Open

Resection

Laparoscopic

Resection

Single Port

Access SurgeryMRgFUS

Transarterial

Chemoembolization Selective Internal

Radiation Therapy

(SIRT)

Hyperthermia

Breast

MRI

Virtual

Colonoscopy

Chemotherapy Oral

Chemotherapy

Targeted

Therapies

Vaccine Therapy

Genetic

Counseling

Genetic Testing

SPECT

Gene Therapy

Hormone

Therapy

CT Lung

Screening

Breast-Specific

Gamma Imaging

Positron Emission

Mammography

25th Percentile 50th Percentile 95th Percentile

Treatment Types

37Chemo (Medical) Radiation Surgery

Hormone Therapy Biologic Therapy

Despite Innovation, Surgery Still Reins Supreme

Prevalence of Use of Primary Treatment Approaches, by Tumor Site

Treatment

ModalityProstate NSCLC SCLC Breast Colon Rectal Bladder Cervical Uterine

Renal

PelvisMelanoma

Surgery X X X X X X X X X X

RT X X X X X X X

Chemotherapy X X X X X

Hormone

TherapyX X X

Immunotherap

y

“X” denotes use of particular therapy in 20 percent or more of primary treatments

Surgery

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Surgical Oncology

Image: Colon Cancer Surgery

Chemotherapy

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Chemotherapy

Clinical Trials• Clinical Trials for Chemotherapy Treatments

• Taking Part in a Trial

• Understanding Cancer Research Trials

• Duration of Research

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Radiation Therapy

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Radiation Therapy

Stereotactic Radiosurgery

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Proton Beam Therapy• The most expensive, resource intensive medical technology

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Easing Side Effects

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Supportive Care

Anemia Drugs

•Epoetin

•Procrit

•Aranesp

Neutropenia Drugs

•Neulasta

•Neupogen

Antiemetics

•Emend

•THC?

Complementary/Alternative Medicine

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CAM

Acupuncture ChiropracticHomeopathy

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IV

Key Strategic Concerns

Cost of Cancer Care

Source: American Cancer Society, available at: http://www.cancer.org/cancer/cancerbasics/economic-impact-of-cancer, accessed August 23 2010 ; Milliman Client Report, “Cancer Patients receiving Chemotherapy: Opportunities for Better Management” available at: http://publications.milliman.com/research/health-

rr/pdfs/cancer-patients-receiving-chemotherapy.pdf, accessed August 23 2010 ; Oncology Roundtable interviews and analysis.

Rapid Rise in Oncology Costs in the Spotlight

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$111,000

Average drug costs per chemotherapy patient

$22,353

Average cost of care of patient receiving chemotherapy

20082004

$72B

$93B

29% increase

Essential to Streamline Care Process to Manage Future Demand

Cancer Care Ripe for Reform

Source: Oncology Roundtable interviews and analysis.

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Demographics Complexity of Care

Variability in Utilization and Outcomes

Cost Burden

Poor Care Coordination

Clinical Innovation

Provider Shortage

Baby boomers reaching period of

highest cancer incidence

Increasing multi modal therapy;

growing survivor needs

Significant variation in treatment pattern and outcomes, lack of

comparative data to inform treatment decisions

Sky rocketing cost of care per patient

Numerous transitions across providers, sites of care

Emergence of new, costly treatments (e.g., proton beam

therapy, targeted therapies

Forecast shortage of medical oncologists.

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ABC Resources

I. Oncology Roundtable

II. Technology Insights

III. Innovations Center

ABC Offerings Impact Oncology Services

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2010-2011 Oncology Roundtable Meeting Series

Transforming Cancer Care• Assessing health care reform’s impact on the delivery of cancer care

• Organizing for accountable care

• Implementing clinical pathways to drive care standardization

Elevating Referral Strategy• Identifying key drivers of physician preference

• Leveraging technology to improve communication with referring

physicians

• Enhancing outreach to community physicians

Delivering on the Promise of Patient-Centered

Care• Expediting access to care

• Optimizing patient navigation models

• Organizing services to meet survivors’ needs

• Delivering on service excellence

Additional Resources

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For More Information

NCI

American Cancer Society

ASTRO

ASCO

Oncolink

MD Anderson

NCCN

Oncology Roundtable: Allison Cuff, x5713

Innovations Center: Joe McCaffrey, x6208

Technology Insights: Matt Garabrant, x6341

Or call me with any clinical issue: Lisa

Bielamowicz, x6340