Executive Medical Staff: Report of the Cancer Committee

November 12, 2013

Urjeet A. Patel, MD FACS

Stroger Hospital of Cook County

Chairman

Division of Otolaryngology

Head/Neck Surgery

Chairman

Cancer Committee

Cancer Committee

Urjeet A. Patel, MD Chairman

Gianlucca Lazarro, MD Cancer Liaison MD

Patrick Dunne, MD Radiology

Thomas Lad, MD Medical Oncology

Ozuru Ukoha, MD Thoracic Surgery

Lillian Hussein, MD Medical Oncology

Elizabeth Marcus, MD Breast Surgery

Marin Sekosan, MD Pathology

Karen Ferrer, MD Pathology

Andrew Kulic, MD Psychiatry

Harish Thakrar, MD Rad. Oncology

Patricia Vidal, MD Urology

Donald Trepashko, MD Nuclear Medicine

Gloria Hart, CTR Tumor Registry

Catherine Strong, RN Nursing

Catherine Deamant, MD Palliative Care

Krishna Das, MD Quality Assurance

Hazel Feliciano Social Work

Ernestine Daniels Pastoral Care

Brienda Averhart Comm.Rep.

Edgardo Yordan, MD Gyne. Oncology

Erika Radeke CCOP Clin.Trials

Cancer Committee

• Regulatory Issues

• Cancer Stats for this year

• Programmatic studies and endeavors

• Future Considerations

Regulatory Issues

3-year cycle of accreditation by the Commission on Cancer: American College of Surgeons July 16, 2013: one day site visit Reviewed as an Academic Comprehensive Cancer Program Participation from Drs. Fegan and Shannon, and the Cancer Committee

Accreditation

Standard 1.9: Clinical trial accrual

Standard 1.11: Cancer Registrar Education

Standard 2.2: Nursing Care: 25% with oncology certification

Performance Report: Areas of Commendation

Accredited for 3 years, with contingency

Will require corrective action moving forward to address any outstanding deficiencies

Re-Accreditation Action Plan

Tumor Board Presentations

Tumor Board Presentation 2007 2008 2009 2010 2011 2012

Breast 6 2 2 2 2 1

Lung 5 4 3 3 5 4

Head/Neck Esophageal 7 5 9 5 11 5

Upper GI 16 10 16 21 25 25

Lower GI 8 9 7 5 3 4

Hepatobillary 3 9 8 2 6 3

GU 16 19 13 9 3 4

Gyne 4 2 6 3 4 9

Soft Tissue 17 6 32 41 23 28

Leukemia/Lymphoma 14 11 1 8 1 2

Brain 14 12 3 2 2 2

Other 6 4 5 3 8 9

TOTAL 116 93 105 104 92 96

Multidisciplinary Tumor Conferences

Breast Conference Thursday morning 8am

Thoracic Oncology Conference Monday morning 7:30 am

Head/Neck Cancer Conference Tuesday at 3pm

Gyn/Onc Conference Wednesday 8:30 am

Gastrointestinal Oncology Conference 2nd and 4th Thursday 2pm of the month.

Leukemia/Lymphoma Conference Wednesday 12-1pm and Friday 1-2 pm.

Soft Tissue and Melanoma Conference Tuesday at noon

Neuroendocrine Tumor Conference Quarterly meeting

Endocrine: Thyroid Monthly 3rd Thursday

GU Monthly 3rd Fri

JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY 2012 CANCER STATISTICS

In 2012, John H. Stroger, Jr. Hospital of Cook County (JHSH) recorded 1,677 with 1,612 analytic cancer patients, showing a slight

increase of over 1,600 cases within the last 10 years. This increasing trend in the number of analytic patients is reflected in (see graph, S9)

of the annual report The patient population treated at JHSH remains predominantly Black/African American 52% (see graph, S3), with

(780) 48% female and 832) 52% male (see graph, S4).

The patients’ overall age range distribution was from 8 to 90+ years, with the peak age range between 50 to 69 years for both males and

females, and a mean age of 56 years.

The most common malignancies treated at JHSH include breast, prostate, lung, and colon & rectum cases. They are among the top five

cancer sites and rank closely within the overall national percentage average for these cancer sites (see graph, S5).

The vast majority of new cancer patients were diagnosed and/or treated at JHSH and are classified as analytic cases. A small number of

patients were diagnosed and treated elsewhere and are classified as non-analytic cases (see graph, S7). The overwhelming majority of new

analytic cancer patients were categorized as Class 10–14, patients in that they were both diagnosed and treated exclusively at JHSH (see

graph, S7).

A large number of JHSH patients are diagnosed with late-stage disease (see graph, S8).

Multimodal therapeutic regimens were often utilized to treat advanced stage cancer patients that presented to JHSH. The most commonly

modalities used in the treatment of cancer patients includes (Chemotherapy, Radiation Therapy, and Surgery), in various combinations [see

graph, S8].

In spite of the fact that more JHSH cancer patients present with relatively advanced disease than in the general population (nationwide)

94% of these patients were alive at the time of this report (see graph, S10), and the vast majority of cancer patients seen at JHSH lived in

Cook County.

Black52%

White

37%

Asian9%

Unknown

2%

John H. Stroger, Jr. Hospital of Cook County

2013 Cancer Committee Annual Report 2012 Analytic Race Distribution

52%

Female, 48%

John H. Stroger, Jr. Hospital of Cook County2012 Analytic Gender Distribution

Male Female

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

Lung Breast Prostate Colon & Rectum Hematopoietic & reticuloendo System

12.66%

11.60% 11.60%

9.37%

5.83%

13.98% 13.82%

14.61%

9.17%

7.39%

13.80% 13.84%

14.75%

8.75%

7.16%

Per

cen

tage

%

Sites

John H. Stroger, Jr. Hospital 2013 Cancer Committee Annual Report Top Five Cancer Sites Comparison Graph

JHSH IL US

Source: ACS Cancer Facts & Figures 2012,

estimated New Cancer Cases for Illinois and United

States

STROGER HOSPITAL OF COOK COUNTY

Summary By Body System and Sex Report

All Other Sites - 202 (24%) All Other Sites - 238 (31%)

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

Non-Hodgkin Lymphoma - 29 (3%) Non-Hodgkin Lymphoma - 18 (2%)

Melanoma of the Skin - 10 (1%) Melanoma of the Skin - 5 (1%)

Leukemia - 27 (3%) Leukemia - 21 (3%)

Urinary Bladder - 29 (3%) Ovary - 29 (4%)

Colon & Rectum - 96 (12%) Uterine Corpus - 74 (9%)

Prostate - 187 (22%) Colon & Rectum - 77 (10%)

Thyroid - 38 (5%)

Lung & Bronchus - 79 (10%)Lung & Bronchus - 125 (15%)

Breast - 184 (24%)

Pancreas - 26 (3%)

Kidney & Renal Pelvis - 34 (4%) Kidney & Renal Pelvis - 17 (2%)

Males Females

Oral Cavity & Pharynx - 67 (8%)

Class 00 1%

Class 10-14 80%

Class 20-22 15%

Class 30-32 4%

John H. Stroger, Jr. Hospital of Cook County 2012 Total Class of Case Percentage Distribution

Stage 03%

Stage I25%

Stage II17%

Stage III16%

Stage IV25%

Stage 889%

Unk7%

John H. Stroger, Jr. Hospital of Cook County 2013 Cancer Committee Annual Report

Analytic Best CS/AJCC Stage Distribution

Stage 0 Stage I Stage II Stage III Stage IV Stage 88 Unk

Surgery 31%

Chemotherapy 29%

Radiation Therapy 25%

Hormone 3%

Other 3%

No treatment 9%

2012 1st Course Treatment Modalities Distribution

Alive 94%

Dead 6%

John H. Stroger, Jr. Hospital of Cook County 2013 Cancer Committee Annual Report

Analytic Cases Vital Distribution

Alive Dead

THE COOK COUNTY HOSPITAL CANCER REGISTRY

The Cancer Registry is utilized to collect and report various relevant parameters

regarding cancer patients such as race, age, and type of cancer. Such data

collection gives important insight to evaluate.

• Cancer incidence trends

• Adequacy of work-up

• Therapeutic results

• Adequacy of follow-up

The Cancer Registry supports the hospital cancer program as well as affiliated

community health projects, including cancer screening and cancer

education.

Cancer data once collected is electronically transmitted to both the State of

Illinois Cancer Registry and the National Cancer Data Base.

The Cancer Registry standards are monitored and kept in line with American

College of Surgeon Commission on Cancer guidelines.

CANCER REGISTRY AND CLERICAL STAFF

Gloria Hart, CTR – Supervisor

Constance Johns, RHIA,CTR – Supervisor hired September 2013

Denise Henry – Clerk V

Carolyn Vazquez – Clerk V

Virginia Williams – Clerk V

2012 SUMMARY OF STUDY PARTECIPATION

REPORTING OF REGISTRY DATA

Illinois State Cancer Registry……………………………..Annual Data Transmission

(No studies offered)

American College of Surgeons/………………………….. Annual Data Transmission

National Cancer Data Base (No studies offered)

Hospital Cancer Committee Internal Studies:

•Cancer Committee Chairman – Bureau wide Cancer Program Presentation

•Cook County Bureau Administration – Breast, Head/Neck, & Prostrate Study

•Hematology/ Oncology – CML Study

•Medical Oncology – 2012 Colon-Rectal Cancer Study

•Medical Oncology – 2012 Lymphomas HL & NHL Study

•Medical Oncology – Ovarian Cancer Study

•Medical Oncology – QA Report

•Medical Oncology – 2012 Lung Cancer Study

•Research & Education – 2010 Analytic Primary Site & Stage Distribution

•Research & Education – 2011 Analytic Primary Site & Stage Distribution

•Research & Education – 2012 Cancer Registry Follow-up Requests

•Surgical Oncology - 2012 Kidney Cancer Study

•Surgical Oncology – 2012 NCDB (CP3R) Breast, Colon & Rectal Comparison

Clinical Trials

Minority-Based Community Clinical Oncology Program (MB-CCOP) NCI funded grant Scope: enrollment of patients on NCI-sponsored cancer treatment and cancer control studies – PI: Tom Lad; Associate PI: Urjeet Patel – >$3 million for 5 years

In place at Stroger for 10+ years; Changing funding mechanism; New Application came out this week; <2 months Will require timely cooperation from senior administration, Dept. chairs

SHCC MB-CCOP Personnel

Personnel: Role 100% external Funding Erika Radeke Administrator NCI Marisol Soto Secretary NCI Nicole Acosta Regulatory Affairs NCI Wendy Rogowski PAC Head CRA NCI Vanessa Barrera CRA NCI Karen Carter CRA NCI Barbara Lucasczcyk CRA NCI Almae Uy CRA NCI Tomas Mackevicius Information Officer NCI Deneisha Brown Contract CRA NCI Namrata Das Batra Contract CRA NCI Ariel Chavez PAC CRA Rush Agreement Barbara Cleveland RN RN Rush Agreement (1/3) Marciana Bowen RN RN Rush Agreement Augustine Haidau Heme/Onc Div. funds Khosrow Zarei Heme/Onc Div. funds

SHCC MB-CCOP Accrual

2007 2008 2009 2010 2011 2012 2013

ACOSOG 1

BCIRG

CALGB 4 8 5 28 64 41 3

CCCWFU 3 9 7

ECOG 79 39 21 43 14 5 3

GOG 3 13 11 3

IBCSG

MOFFITT/SCUFS 2 7 17 6 1

NCCTG 4 2

NCIC 10 1

NSABP 26 12 6 14 4 14 7

RTOG 9 17 20 33 11 20 5

SWOG 2 2 2 14 4

UMBCCOP

Non-NCI 34 36 9 4 0 30 22

Total 154 125 80 130 115 154 56

QI/QA Projects

Considering projects to track positive pathology results: global project with Dr. Das

Palliative care: project underway to improve quality of deaths of patients under palliative care with use of comfort care order set

Considering goal of improving oral care for head/neck cancer patients (pre-xrt treatment, dentures, etc)

Establish Cancer Survivorship plan, and psychosocial assessments of cancer patients

Site-Specific analysis of Pancreatic Cancer; Dr. Gupta

Annual Report will be posted online

Conclusions

Stroger Hospital/CCHHS is providing state-of-the-art comprehensive cancer care, though we are questionably belows standards set by the Commission on Cancer

High-quality care delivered

Deficiencies to be resolved, though more stringent requirements pending

Additional resources/IT support will be required to comply to increasingly stringent program requirements:

Tumor Registry: currently understaffed; further training/staffing required

Pathology: must better support site-specific cancer conferences

New standards: Survivorship planning, psychosocial screening, community-needs-based assessment of screening programs

Final analysis for 2013 work-product pending

Cancer Committee Annual Review 2013

Cancer site review – Pancreas

Shweta Gupta, MD Attending Physician

Div of Hematology-Oncology John H Stroger Jr. Hospital of Cook County

Risk Factors RISK FACTOR RELATIVE RISK

Smoking 2 – 5

DM 2

High BMI 2

Chronic Pancreatitis 13 – 18

Hereditary Pancreatitis 10 – 53

FAMMM syndrome 22

HNPCC 8

Peutz-Jeghers 13 – 30

Familial adnomatous polyposis 4 – 5

Li-Fraumeni ?

BRCA2 3 – 5

Clinical Presentation

• Jaundice (50% of patients)

• Weight loss

• Anorexia

• Bloating

• Steatorrhea or diarrhea

• Abdominal pain or back pain or both

Diagnosis

• Abdominal Ultrasound

• CT Abdomen

• Biopsy (Percutaneous or Endoscopic)

• Serum CA 19-9

– Elevated in 80% of pancreatic ca cases

– Low specificity

– If elevated can be used to follow during therapy

Staging

Treatment

• Localized: Radical pancreatic resection +/- post-op radiation and/or chemotherapy

(5-FU or gemcitabine)

• Locally Advanced: chemotherapy +/-radiation or clinical trial

• Metastatic Disease:

chemotherapy (gemcitabine)

• 20% of potentially resectable disease would be unresectable at surgery

• Surgical morbidity and mortality is inversely proportional to experience of the surgical center

– Not related to postoperative care

Treatment

• At the time of diagnosis: – 15-20% of pts have localized and resectable tumors – 40-45% have localized tumors that are unresectable

(generally due to vascular invasion) – 40-45% have distant metastases

• Contraindications to surgical resection: – Mets to liver, peritoneum, omentum, or any extra-

abdominal site – Encasement of celiac axis, hepatic artery or SMA – Involvement of splenoportal confluence – Involvement of bowel mesentary – Involvement of SMV or portal vein

• Positive surgical margin = very poor prog

AUTHOR N Margin status Median survival

Sohn 184 R1/R2 12

Neoptolemos 101 R1 11

Nishimura 70 R1/R2 6

Millikan 22 R1 8

Richter 72 R1/R2 12

Kuhlman 80 R1/R2 16

Takai 42 R1/R2 8

• Surgically resected patients remain at risk of local failure or metastatic disease

• 80% recur

• Perineural invasion is an important mediating factor

NEOADJUVANT

Author N Regimen Resection rate

% R1 Median survival

Evans 1992 28 5FU + XRT 50.4 Gy 61 ? 18

Pisters 1998 35 5FU + XRT 30 Gy

57 10 25

Pisters 2002 37 Taxol + XRT 30 Gy

54 32 19

Evans 2008 86 Gem + XRT 30 Gy 75 12 34

Vardhachar2008

90 Cis/Gem then Gem + XRT 30 Gy

58 4 31

• Not the standard of care

• Should be considered for borderline resectable disease

– Remember of all patients deemed resectable and taken for surgery, 20% are found to be unresectable

• Reassess after neoadjuvant regarding resectability

ADJUVANT

Study R1 resection Arm A (survival-mo)

Arm B (survival-mo)

P-value

GITSG 1985 0 5FU/XRT 21

Observe 10.9

0.035

EORTC 1999 19 5FU/XRT 17.1

Observe 12.6

0.099

ESPAC-1 2004 18 5FU/LV 20.1

5FU/XRT 15.9

No 5FU/LV 15.5

No 5FU/XRT 17.9

0.009

0.05

RTOG 9704 2008

>35 Gem+5FU/RT 20.5

FU + FU/RT 16.9

0.09

CONKO 001 2008

19 Gem 22.8

Observe 20.2

0.005

ESPAC1+3 2009 25 5FU/LV 23.2

Observe 16.8

0.003

ESPAC 3 35 Gem 23.6

5FU/LV 23

0.39

Potentially resectable

• Carefully select for surgery

• Always attempt to give adjuvant chemo

• Adjuvant RT is may be added (RTOG 9704)

• Neoadjuvant for very selective cases

Cancer site review - methods

• We looked at all patients who were diagnosed with pancreatic cancer as per our tumor registry records from 2006 to 2012

• All charts were retrospectively reviewed for details

• 308 patients were screened

• 280 confirmed to have pancreatic adenocarcinoma and were reviewed in detail

Epidemiology

• 4th leading cause of cancer death in US

• Estimated new cases and deaths 2013:

– Cases 45,220

– Deaths 38,460

Stroger

47

41

32 36

41 41 41

0

10

20

30

40

50

60

2006 2007 2008 2009 2010 2011 2012

Cases

Cases

2010 numbers

US IL COOK COUNTY STROGER HOSP

DIAGNOSED 38,142 1705 727 41

DEATH 35,064 1494 635 23 **

There are 120 hospitals with adult patient intake in Cook County area We diagnose 5.6 % of all the cook county cases at Stroger

** The exact number unknown

Stroger (n=279)

0 0.7

5.7

30.1

37.9

18.6

5.7

1 0

5

10

15

20

25

30

35

40

<20 20-34 35-44 45-54 55-64 65-74 75-84 >84

percent by age

Median Age 58

M:F ratio

US (SEER) 1.3 : 1

Stroger 1.4 : 1

53

8

19

20

Ethnicity distribution at Stroger

Black

Asian

Hispanic

White

Prognosis

• Overall survival rate 4-5%

• 5 year survival (SEER) = 6%

• For patients with small cancers (<2cm) with no extension beyond capsule of pancreas, complete surgical resection has a 5 year survival rate of 18-24%

• For patients with advanced cancers, survival at 5 years is 1%, with most patients dying within a year

Mortality data

• To an extent not complete

– Hospice follow up

– Lost to follow up

• 5 year survival = 4.6% (SEER number 6%)

– Based on available data

– 152 patients with OS data, 7 reached 5 years

– Stage differences

National numbers

Stroger

24

14 62

Stage (%)

Localized

Unresectable

Metastatic

Surgery for localized disease

• n = 66 patients with stage I or II disease

• 57 underwent surgery (86%)

• 11 patients found to have unresectable disease or incompletely resected grossly (19%)

• 46 patients underwent complete gross resection (R0/R1)

Cases and surgery by year

13 13

5

7

3

15

10

13

11

4

6

3

12

8

-1

1

3

5

7

9

11

13

15

2006 2007 2008 2009 2010 2011 2012

Cases (St I/II)

surgery attempted

Summary

• Stroger being an inner city safety net hospital diagnoses more cases of pancreatic cancer compared to other hospitals in our Cook County area

• We have a higher percentage of advanced stage cancers compared to national average, potentially explaining the small difference in survival

• Surgery is offered to most patients with localized disease except with contraindications to surgery

• 72% of patients post definitive surgery are able to receive adjuvant therapy

Challenges for future

• Better documentation of end points of patients who enroll in hospice may improve our understanding of the true OS for more patients

• Potentially we can improve on accounting for patients who are lost to follow up

Thank You