Cervix Cancer and GASharad Ghamande MD FACOG

Professor and Director Gynecologic Oncology GRU

Associate Director Clinical Affairs GRU Cancer Center Augusta GA

Principal Investigator Minority NCORP GA Cares

64928Europe

67078Africa

49025South America

14845United States

Canada

1077Australia

New Zealand

39648Southeast

Asia

51266Eastern Asia

21596Central America

151297Southcentral

Asia

Cervical Cancer Worldwide Prevalence Incidence and Mortality Estimates

Prevalence 2274000 women have cervical cancerIncidence 510000 new cases each year

80 in developing countries

Mortality Second leading cause of female cancer-related deaths (288000 annually)Estimated individual loss of life 259 years

(Breast Cancer 19 years Ovarian Cancer 174 years)

Cervix Cancer in US

bull American Cancer Society 2015

bull 12900 cases of cervix cancer a year 4100 patients will die of it this year

bull Additionally there are 300000 cases of CIN23 which are true cancer precursors

bull Another 12 million women in US have a low grade dysplasia (CIN 1)

bull Total health care costs of screening and treating cervix cancer are estimated at 6 billion dollars a year

1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28

3 ACS Facts amp Figures 2009

High Impact of Cervical Cancer amp Precancerous Lesions in the United States

Every minute a woman is diagnosed with a precancerous lesion2ab

Every 2 hours a woman dies of cervical cancer3a

Every hour a woman is diagnosed with cervical cancer3a

aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23

In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391

GA Racial Distribution

bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was

bull 597 White American (559 Non-Hispanic White 38 White Hispanic)

bull 305 Black or African American (including Hispanics)

bull 03 American Indian and Alaska Native (including Hispanics)

bull 32 Asian American (including Hispanics)

bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)

bull 40 from Some Other Race (including Hispanics)

bull 21 Multiracial American (including Hispanics)

bull 88 Hispanics and Latinos of any race[5]

64928Europe

67078Africa

49025South America

14845United States

Canada

1077Australia

New Zealand

39648Southeast

Asia

51266Eastern Asia

21596Central America

151297Southcentral

Asia

Cervical Cancer Worldwide Prevalence Incidence and Mortality Estimates

Prevalence 2274000 women have cervical cancerIncidence 510000 new cases each year

80 in developing countries

Mortality Second leading cause of female cancer-related deaths (288000 annually)Estimated individual loss of life 259 years

(Breast Cancer 19 years Ovarian Cancer 174 years)

Cervix Cancer in US

bull American Cancer Society 2015

bull 12900 cases of cervix cancer a year 4100 patients will die of it this year

bull Additionally there are 300000 cases of CIN23 which are true cancer precursors

bull Another 12 million women in US have a low grade dysplasia (CIN 1)

bull Total health care costs of screening and treating cervix cancer are estimated at 6 billion dollars a year

1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28

3 ACS Facts amp Figures 2009

High Impact of Cervical Cancer amp Precancerous Lesions in the United States

Every minute a woman is diagnosed with a precancerous lesion2ab

Every 2 hours a woman dies of cervical cancer3a

Every hour a woman is diagnosed with cervical cancer3a

aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23

In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391

GA Racial Distribution

bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was

bull 597 White American (559 Non-Hispanic White 38 White Hispanic)

bull 305 Black or African American (including Hispanics)

bull 03 American Indian and Alaska Native (including Hispanics)

bull 32 Asian American (including Hispanics)

bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)

bull 40 from Some Other Race (including Hispanics)

bull 21 Multiracial American (including Hispanics)

bull 88 Hispanics and Latinos of any race[5]

Cervix Cancer in US

bull American Cancer Society 2015

bull 12900 cases of cervix cancer a year 4100 patients will die of it this year

bull Additionally there are 300000 cases of CIN23 which are true cancer precursors

bull Another 12 million women in US have a low grade dysplasia (CIN 1)

bull Total health care costs of screening and treating cervix cancer are estimated at 6 billion dollars a year

1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28

3 ACS Facts amp Figures 2009

High Impact of Cervical Cancer amp Precancerous Lesions in the United States

Every minute a woman is diagnosed with a precancerous lesion2ab

Every 2 hours a woman dies of cervical cancer3a

Every hour a woman is diagnosed with cervical cancer3a

aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23

In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391

GA Racial Distribution

bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was

bull 597 White American (559 Non-Hispanic White 38 White Hispanic)

bull 305 Black or African American (including Hispanics)

bull 03 American Indian and Alaska Native (including Hispanics)

bull 32 Asian American (including Hispanics)

bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)

bull 40 from Some Other Race (including Hispanics)

bull 21 Multiracial American (including Hispanics)

bull 88 Hispanics and Latinos of any race[5]

1 Jemal A et al CA Cancer J Clin 200959225-492 Saslow D et al CA Cancer J Clin 2007577-28

3 ACS Facts amp Figures 2009

High Impact of Cervical Cancer amp Precancerous Lesions in the United States

Every minute a woman is diagnosed with a precancerous lesion2ab

Every 2 hours a woman dies of cervical cancer3a

Every hour a woman is diagnosed with cervical cancer3a

aEstimatedbPrecancerous lesion = cervical intraepithelial neoplasia (CIN) grades 23

In the United States cervical cancer is the second leading cause of cancer-related death in women between the ages of 20 and 391

GA Racial Distribution

bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was

bull 597 White American (559 Non-Hispanic White 38 White Hispanic)

bull 305 Black or African American (including Hispanics)

bull 03 American Indian and Alaska Native (including Hispanics)

bull 32 Asian American (including Hispanics)

bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)

bull 40 from Some Other Race (including Hispanics)

bull 21 Multiracial American (including Hispanics)

bull 88 Hispanics and Latinos of any race[5]

GA Racial Distribution

bull According to the 2010 US Census Georgia had a population of 9687653 In terms of race the population was

bull 597 White American (559 Non-Hispanic White 38 White Hispanic)

bull 305 Black or African American (including Hispanics)

bull 03 American Indian and Alaska Native (including Hispanics)

bull 32 Asian American (including Hispanics)

bull 01 Native Hawaiian and Other Pacific Islander (including Hispanics)

bull 40 from Some Other Race (including Hispanics)

bull 21 Multiracial American (including Hispanics)

bull 88 Hispanics and Latinos of any race[5]

How can we make an impact

1) Prevention

- Widespread use of Pap smears

- Improve Vaccination

2) Treat CIN 23 and prevent invasive cancers ( Insurance and access barriers)

3) Improve the care and outcomes of women with cervix cancer

Cervical Cancer Have We Decreased the Incidence in the US

bull The curve has been stable for the past decade in part because we are not reaching the unscreened population

With the advent of the Pap smear the incidence of

cervical cancer has

dramatically declined

74 decline in death from 1955 to 1992

Reprinted by

permission of the

American Cancer

Society Inc

CIN 2-3 rates

bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women

bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per

1000

bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000

bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1

bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]

[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36

Costs of Treating Cervical Cancer

bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C

bull BACKGROUND

bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000

bull METHODS

bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls

bull FINDINGS

bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively

bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively

bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002

Cervical Cancer Have We Decreased the Incidence in the US

bull The curve has been stable for the past decade in part because we are not reaching the unscreened population

With the advent of the Pap smear the incidence of

cervical cancer has

dramatically declined

74 decline in death from 1955 to 1992

Reprinted by

permission of the

American Cancer

Society Inc

CIN 2-3 rates

bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women

bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per

1000

bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000

bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1

bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]

[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36

Costs of Treating Cervical Cancer

bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C

bull BACKGROUND

bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000

bull METHODS

bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls

bull FINDINGS

bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively

bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively

bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002

CIN 2-3 rates

bull Annual incidence of CIN 1 is 16 CIN 23 is 12 per 1000 women

bull Incidence is highestbull women aged 21 ndash 30 years with CIN 1 is 33 per 1000 and CIN 23 is 36 per

1000

bull women aged 31 ndash 40 years with 29 per 1000 for CIN1 and CIN 23 is 27 per 1000

bull Costs per episode of care was higher for CIN 23 than for CIN 1bull $ 1634 for CIN 23 vs $ 1084 for CIN 1

bull Estimated 412000 women are diagnosed with CIN annually with an associated cost of approximately $570 million [1]

[1] Henk et al Incidence and costs of cervical intraepithelial neoplasia in a US commercially insured population J lower tract dis 2010 Vol 14 29-36

Costs of Treating Cervical Cancer

bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C

bull BACKGROUND

bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000

bull METHODS

bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls

bull FINDINGS

bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively

bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively

bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002

Costs of Treating Cervical Cancer

bull Cost of cervical cancer treatment implications for providing coverage to low-income women under the Medicaid expansion for cancer care Subramanian S1 Trogdon J Ekwueme DU Gardner JG Whitmire JT Rao C

bull BACKGROUND

bull To date no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000

bull METHODS

bull Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls

bull FINDINGS

bull Total Medicaid costs at 6 months after diagnosis were $3807 $23187 $35853 and $45028 for in situ local regional and distant cancers respectively

bull The incremental cost of cancer treatment for local and regional cancers was $13935 and $26174 and by 12 months increased to $15868 and $30917 respectively

bull 2010 Nov-Dec20(6)400-5 doi 101016jwhi201007002

Cervical Cancer ndash Risk Factors

bull Multiple sexual partners

bull Early age onset intercourse

bull Parity

bull HO STDrsquos

bull Smoking

bull Low socioeconomic status

bull Use of Oral Contraceptives

bull High risk male partner

Cervical Cancer - Risk Factors

bull HIVbull RR 52-65 of cervical cancer

bull 1993 CDC AIDS defining illness

bull mean age at diagnosis 40

bull HPVbull OR 1582 for HPV

bull High risk 1618453133525835

0 20 40 60 80 100

16

18

45

31

HPV X

33

52

58

35

59

56

576

717

774

813

85

879

901

918

933

946

957

HPV types from 3045 Women with Cervical Cancer in 23 countries

HPV vaccination

bull HPV 4bull Approved for females and males 9 ndash 26

bull Contains HPV 1618611

bull HPV 2bull Approved for females and males 9 ndash 25

bull Contains HPV 1618

bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258

HPV vaccination in GA adolescentsYear Females Males

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3 HPV ( 95CL)

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3HPV ( 95CL)

2014 654 563 471 412 280 210

2013 537 423 332 405 310 153

2012 523 368 29 195 87 NA

2011 484 NA 300 73 NA NA

2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV

2009 All adolescences gt or = to 1 HPV 386

2008 All adolescences gt or = to 1 HPV 185

Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

Cervical Cancer - Risk Factors

bull HIVbull RR 52-65 of cervical cancer

bull 1993 CDC AIDS defining illness

bull mean age at diagnosis 40

bull HPVbull OR 1582 for HPV

bull High risk 1618453133525835

0 20 40 60 80 100

16

18

45

31

HPV X

33

52

58

35

59

56

576

717

774

813

85

879

901

918

933

946

957

HPV types from 3045 Women with Cervical Cancer in 23 countries

HPV vaccination

bull HPV 4bull Approved for females and males 9 ndash 26

bull Contains HPV 1618611

bull HPV 2bull Approved for females and males 9 ndash 25

bull Contains HPV 1618

bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258

HPV vaccination in GA adolescentsYear Females Males

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3 HPV ( 95CL)

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3HPV ( 95CL)

2014 654 563 471 412 280 210

2013 537 423 332 405 310 153

2012 523 368 29 195 87 NA

2011 484 NA 300 73 NA NA

2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV

2009 All adolescences gt or = to 1 HPV 386

2008 All adolescences gt or = to 1 HPV 185

Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

0 20 40 60 80 100

16

18

45

31

HPV X

33

52

58

35

59

56

576

717

774

813

85

879

901

918

933

946

957

HPV types from 3045 Women with Cervical Cancer in 23 countries

HPV vaccination

bull HPV 4bull Approved for females and males 9 ndash 26

bull Contains HPV 1618611

bull HPV 2bull Approved for females and males 9 ndash 25

bull Contains HPV 1618

bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258

HPV vaccination in GA adolescentsYear Females Males

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3 HPV ( 95CL)

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3HPV ( 95CL)

2014 654 563 471 412 280 210

2013 537 423 332 405 310 153

2012 523 368 29 195 87 NA

2011 484 NA 300 73 NA NA

2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV

2009 All adolescences gt or = to 1 HPV 386

2008 All adolescences gt or = to 1 HPV 185

Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

HPV vaccination

bull HPV 4bull Approved for females and males 9 ndash 26

bull Contains HPV 1618611

bull HPV 2bull Approved for females and males 9 ndash 25

bull Contains HPV 1618

bull A 9-valent vaccine licensed in December 2014bull Contains additional 5 HPV types 3133455258

HPV vaccination in GA adolescentsYear Females Males

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3 HPV ( 95CL)

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3HPV ( 95CL)

2014 654 563 471 412 280 210

2013 537 423 332 405 310 153

2012 523 368 29 195 87 NA

2011 484 NA 300 73 NA NA

2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV

2009 All adolescences gt or = to 1 HPV 386

2008 All adolescences gt or = to 1 HPV 185

Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

HPV vaccination in GA adolescentsYear Females Males

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3 HPV ( 95CL)

gt 1 HPV ( 95CL)

gt 2 HPV ( 95CL)

gt 3HPV ( 95CL)

2014 654 563 471 412 280 210

2013 537 423 332 405 310 153

2012 523 368 29 195 87 NA

2011 484 NA 300 73 NA NA

2010 All adolescences 435 received gt or = 1 HPV 228 received gt or = to 3 HPV

2009 All adolescences gt or = to 1 HPV 386

2008 All adolescences gt or = to 1 HPV 185

Estimated vaccination coverage among adolescents aged 13--17 years by state and selected areas and selected vaccinesand doses --- National Immunization Survey--Teen United States 2008 ndash 2014 MMWR ndash CDC cdcgovmmwrreview

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among females aged13ndash17 years (United States National Immunization SurveyndashTeen 2014)

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

Estimated vaccination coverage with ge1 dose of human papillomavirus (HPV) vaccine among males aged 13ndash17 years (United States National Immunization SurveyndashTeen 2014)

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

HPV Vaccination

bull CDC

bull If we increase vaccination rates to 80 an additional 53000 new cases of invasive cervix cancers could be prevented in the life time of those younger than 12 years

bull For very additional year increase an additional 4400 women will go on to have cervical cancer

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

HPV vaccine recommendations

bull ACIP recommends routine vaccination at age 11 or 12 with HP4 for males and females and HPV 2 for females

bull Vaccination schedule is 01-2 6 months

bull ACOG and CDC proclaim that ldquothe current vaccination rates are unacceptablerdquo

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

Can we create centers of excellence for cancer care

bull Impact of facility volume on therapy and survival for locally advanced cervical cancer

bull Jeff F Lin a Jessica L Berger a Thomas C Krivak ab Sushil Beriwala John K Chan c Paniti Sukumvanich a Bradley J Monk de Scott D Richard

bull Gynecologic Oncology 132 (2014) 416

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

Lin et al

bull Methods The National Cancer Data Base was queried for patients with stage IIB ndash IIIB cervical cancer from 11998 through 122010 Facility volumes were tallied Overall survival was estimated using KaplanndashMeier method Univariate and multivariable analyses were performed to determine variables affecting survival receiving standard therapy and total duration of radiotherapy

bull Results Total of 27660 patients were treated at 1361 facilities Thirty of the facilities (22) treated the highest quartile volume of patients (94 patients annually) while 1072 facilities (788) treated (24 patients annually)

bull The median age of patients was 53 the majority were Caucasian treated in a metropolitan area and of squamous cell histology

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

Lin et al

bull Median survival of patients treated at lowest- and highest volume centers were 423 months (95 CI 398ndash448) and 538 months (501ndash575) respectively (p b 0001)

bull The proportions of patients receiving brachytherapy and chemotherapy were 548 and 799 respectively

bull On multivariable analysis higher facility volume independently predicted improved survival (p = 0022) increased likelihood of receiving brachytherapy (p b 00005) and chemotherapy (p = 0013) and shorter time to radiotherapy completion (p b 00005)

bull Conclusions Patients with locally advanced cervical cancer treated at high volume centers are more likely to receive standard therapy complete therapy sooner and experience better survival

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care

Paradigm Shift in Care

bull Encouragement towards shifting care towards High Volume subspeciality staffed institutions

bull Emerging survival data

bull Clinical trials participation

bull Multi Disciplinary team approach

bull Technological advances ( PETCTrsquos Robot assisted radical surgeries)

bull Individualization of care