(2008 Statistical Data)

2009 CANCER PROGRAM ANNUAL REPORT

MissionExcellent care, every time

VisionTo be the provider of choice

Core ValuesSafetyQualityCompassionAccountability

Our Team

The Mahr Cancer Center

2

Dr. Satish J. ShahRadiation Oncology

Dr. Muhammad K. SiddiqueHematology, Oncology

Dr. Suresh DevineniHematology, Oncology

About our facility Trover Health System’s Merle M. Mahr Cancer Center provides a comfortable, caring atmosphere for patients

to visit their physicians through office appointments and receive chemotherapy or radiation treatments.

State-of-the-art treatment is provided through highly qualified, specially trained clinicians and support staff.

Patients are our focus, and we strive to meet each patient’s individual needs.

Trover Health System diagnoses more than 435 cancer patients each year. This translates to more than

10,000 patient visits annually to the Mahr Center. The Mahr Cancer Center helps patients fight the disease

and cope with their diagnosis through a wide range of services, programs and technology provided by

Trover.

The Merle M. Mahr Cancer Center is Kentucky’s oldest comprehensive cancer center to consistently hold

accreditation with the American College of Surgeons. The center has been accredited since 1976. The

Approvals Program sets standards for cancer care and reviews those programs to ensure they conform to

the high standards set by the American College of Surgeons.

Approval by the Commission on Cancer is earned only by those facilities that have committed to provide

the best in diagnosis, treatment, and prevention of cancer and have successfully completed a rigorous

evaluation process. Approved cancer programs are required to undergo an onsite re-evaluation every three

years. Only slightly more than one-fifth of the country’s hospitals have approved cancer programs, and more

than 80 percent of patients who are newly diagnosed with cancer are treated in these facilities.

3Mahr Cancer Center l 2009 Cancer Program Annual Report 3

4Mahr Cancer Center l 2009 Cancer Program Annual Report

Clinical Services• Weekly Cancer Conference• Physician Office Visits, Chemo and/or Radiation all

in one setting

Radiation Therapy, including IMRT and IGRT• State of the art Radiation planning systems• Radiation planning by a Certified Medical

Dosimetrist and /or Physicist. • Treatment delivery by licensed Radiation Therapists

State of the Art imaging• Pet/CT• MRI• Digital Mammography• Stereotactic Breast Biopsy• Ultrasound Biopsy

Chemotherapy by Certified RN’s• Outpatient Chemo at the Mahr Center• Inpatient Chemo and Oncology services @ RMC,

3 East

Infusion Therapy for patients other than cancer patients, including, but not limited to:• Blood Transfusions• IV antibiotics• IV infusions for Crohns disease• IV infusions for Rheumatoid Arthritis• IV iron

Patient Support/Education• Nutritional Consultation with a Registered Dietician

for all patients• Pastoral/Volunteer Chaplain services• Financial Advocacy • Social Services/Case Management• Home Health/Hospice available by referral

Support Services• Reach to Recovery • Road to Recovery• Cooper Clayton Smoking Cessation in coordination

with WAHEC• Wigs/Head Coverings available free to patients• Relay for Life events• Prayer Line-pt’s/families can leave their prayer

requests

Support Groups• Look Good Feel Better• Becky West Support Group for Breast Cancer

Survivors• General Support Group• Grief Support• Grief Camps

Wellness• Colorectal screening annually• Prostate screening annually• Women’s Screening annually• Participation in Community Health Fairs and Events

Research• Clinical Trials• Affiliated with the Eastern Cooperative Oncology

Group, through Vanderbilt University• Clinical Trial Support Unit, through the National

Cancer Institute• Pharmaceutical Trials• Cancer Registry

Fun• Patient/Family Halloween Party annually• Patient/Family Christmas Party annually• Cooking and Tasting parties by our Registered

Dietician

Our Services at a Glance

4

45Mahr Cancer Center l 2009 Cancer Program Annual Report

The Cancer Committee of Trover Health System is proud to present the 2009 Cancer Program Annual Report. The Cancer Program at Regional Medical Center and the Merle M. Mahr Cancer Center continues to strive for excellence in the care and treatment of our cancer patients. This report demonstrates our efforts at early detection, as well as state-of-the-art cancer care for those patients in the community diagnosed with the nation’s second leading cause of death.

The Mahr Cancer Center has made many strides in improving the care of the cancer patients and giving back to the community. We have continued to make improvements in the area of radiation therapy with IMRT for the treatment of many cancer sites, including head and neck cancers and prostate cancer. This method of delivery of radiation has proven to be safer, produce fewer side effects and provide better outcomes. Many other improvements have been made in the chemotherapy infusion center.

The safety of all patients at Trover is of the utmost importance. Electronic Medical Records were implemented in the Mahr Center’s infusion center for the administration of chemotherapy, providing an extra line of safety in this area. Guidelines provided by the National Cancer Center Network are used routinely by managing physicians to allow patients access to the best possible outcomes while staying close to home.

The cancer program has been continuously accredited by the American College of Surgeon’s Commission on Cancer since 1976. We are currently preparing for a comprehensive survey in the early part of 2010. Since 80 percent of all cancer patients are diagnosed and treated at ACoS accredited programs, this participation allows our cancer program to compare our facilities, experiences and trends with that of the nation’s, through the data submissions to the National Cancer Data Base and participation in the Cancer Program Practice Profile Reports. Our facility has continued to perform comparatively above the benchmark 95 percent in both breast and colorectal cancer treatment. Survival outcomes have continuously benchmarked above state and national averages. The cancer committee recognizes that this is greatly due in part to the prospective multidisciplinary approach to cancer care.

The cancer registry has accessioned more than 13,000 cases since it’s inception in 1973. In 2008, approximately 430 new cancer cases were accessioned into the cancer registry database. The cancer registry staff is continually following an average of 6,300 patients on an annual basis with a success rate of 92 percent. The cancer registry is part of the Kentucky Cancer Registry’s Cancer Patient Data Management System using a modern data encryption system with

patient confidentiality and data security a top priority. Our cancer registry continually exceeds all expectations of data quality as evidenced by audits performed by the state, SEER and NCDB.

The Mahr Cancer Center, in conjunction with Regional Medical Center, Trover Clinic, the Kentucky Cancer Program and the American Cancer Society participate in numerous community outreach programs. Screening and prevention programs offered included breast, prostate and colorectal cancer. These screenings were offered not only at the cancer center, but also in the surrounding counties.

Oncology tumor board conferences are held weekly at Regional Medical Center. In 2008, 142 prospective cases were presented in 39 tumor board conferences. The conferences are attended by members of the medical staff, residents, medical students and other ancillary personnel. Radiographic studies, pathological slides and case information are presented to allow for an open discussion forum including TNM staging and adherence to national treatment guidelines.

Many exciting changes are taking place in the area of cancer care at the Mahr Cancer Center. Most recently, Dr. Suresh Devineni joined Dr. Muhammad Siddique and Dr. Satish Shah to complete the oncology cancer care team. To extend our outreach further in the community, the Mahr Center oncologists will begin seeing patients at the Muhlenberg Medical Center in 2010, providing quality care in a convenient location for patients in Muhlenberg County.

I would like to thank all of the healthcare professionals at Regional Medical Center, Trover Clinic and the Merle M. Mahr Cancer Center. Their dedication, empathy and compassion are the basis for the quality care that is provided by our program. In the following articles and graphs, Dr. Siddique will discuss the diagnosis and treatment of Non-Hodgkin’s lymphoma, one of the top five cancer case sites seen at our facility.

If any further data or graphics are required, please feel free to contact Stacy Littlepage, CTR, at the Cancer Registry at 270.825.5820 or by e-mail at slittlep@trover.org.

Dr. Sarah Elizabeth SnellCancer Committee Chairman

Stacy Littlepage, CTRCancer Registry Coordinator

Chairman’s Report

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2008 Non-Hodgkin’s Lymphoma Histology

Diffuse Large B-Cell 8 (40%)Follicular Lymphoma 4 (20%)Mantle Cell Lymphoma 3 (15%)Small B cell Lymphocytic 2 (10%) Marginal Zone/B-cell 1 (5%)Mature T-Cell Lymphoma 1 (5%)Cutaneous T-Cell Lymphoma 1 (5%)

Non-Hodkin’s Lymphoma Incidence

0

5

10

15

20

25

17

2019

25

20

15

2003 2004 2005 2006 2007 2008

2008 Non-Hodgkin’s Lymphoma by Stage

2008 Non-Hodgkin’s Lymphoma by Therapy

2008 Non-Hodgkin’s Lymphoma by Site

Stage 1EA 4 (20%)Stage IVB 4 (20%)Stage IIA 3 (15%)Stage IIB 3 (15%)Stage IA 2 (10%)Stage IIIB 2 (10%)Stage IVA 2 (10%)

Lymph Nodes, Multiple Regions 9 (45%)Stomach, Nos 2 (10%)Tonsil, Nos 1 (5%)Fundus Of Stomach 1 (5%)Gastrointestinal Tract, Nos 1 (5%)Mediastinum, Nos 1 (5%) Skin Of Scalp And Neck 1 (5%)Conjunctiva 1 (5%)Intra-Abdominal Lymph Nodes 1 (5%)Lymph Nodes Of Inguinal Region 1 (5%)Unknown Primary Site 1 (5%)

No Definitive Rx/observation 8 (40%)Chemo/Other 5 (25%)Chemo Only 4 (20%)Radiation Only 1 (5%)Surgery/Radiation 1 (5%)Chemo/Radiation 1 (5%)

7Mahr Cancer Center l 2009 Cancer Program Annual Report

2008 Non-Hodgkin’s Lymphoma County at Diagnosis

Christian  4  (5.3%)Hopkins  46  (60.5%)McLean  2 (2.6%)Muhlenberg  12  (15.8%)Webster  5  (6.6%)Caldwell  3 (4.0%)Ohio  2 (2.6%)Union  1 (1.3%)Out of state  1 (1.3%)

Christian 3 (15%)Hopkins 12 (60%)McLean 1 (5%)Muhlenberg 2 (10%)Webster 2 (10%)

New Cancer Cases 2008 – Major SitesSite RMC Kentucky National

Lung – (SC & NSC) 19.6% 17.8% 14.9%

Breast, female & male 14.2% 14.7% 12.7%

Colorectal 12.1% 10.7% 10.4%

Prostate 7.9% 10.1% 13.0%

Non-Hodgkins Lymphoma 4.7% 3.7% 4.6%

• National estimated new cancer sites by American Cancer Society “Facts & Figures” 2008• 2008 Regional Medical Center and Kentucky figures are actual to date• Kentucky information obtained from the Kentucky Cancer Registry

2003 NHL Lymphoma Survival

Months Past Diagnosis

% S

urvi

val

Diffuse Large B-Cell 8 (40%)Follicular Lymphoma 4 (20%)Mantle Cell Lymphoma 3 (15%)Small B cell Lymphocytic 2 (10%) Marginal Zone/B-cell 1 (5%)Mature T-Cell Lymphoma 1 (5%)Cutaneous T-Cell Lymphoma 1 (5%)

8Mahr Cancer Center l 2009 Cancer Program Annual Report

2008 Case Frequency Report

All Case Classes Included

Site Total Cases RMC Percent State Percent

Trachea,bronchus,lung-NSC/SC 84 19.58% 17.78%

Breast, female & male 61 14.22% 14.68%

Colon/Rectum 52 12.12% 10.73%

Prostate 34 7.93% 10.13%

Non-Hodgkin's Lymphomas 20 4.66% 3.71%

Kidney 16 3.73% 3.32%

Bladder 15 3.50% 4.05%

Myeloprolif. & myelodysplas. 15 3.50% 1.03%

Malignant melanoma 13 3.03% 5.36%

Endometrium (corpus uteri) 12 2.80% 2.40%

Pancreas 11 2.56% 1.94%

Oropharynx 10 2.33% 0.66%

Unknown primary 9 2.10% 1.65%

Other female genital organs 8 1.86% 1.27%

Esophagus 8 1.86% 0.96%

Lymphocytic leukemias 7 1.63% 0.87%

Plasma cell tumors 7 1.63% 0.95%

Cervix 6 1.40% 0.76%

Liver 4 0.93% 1.01%

Myeloid leukemias 4 0.93% 0.89%

Hodgkin's 3 0.70% 0.44%

Thyroid 3 0.70% 2.38%

Stomach 3 0.70% 1.05%

Larynx 3 0.70% 1.11%

Other urinary organs 3 0.70% 0.49%

Ovary 3 0.70% 1.16%

Lip 2 0.47% 0.17%

Nasopharynx 2 0.47% 0.11%

Connective & soft tissue 2 0.47% 0.49%

Hypopharynx 1 0.23% 0.17%

Other male genital organs 1 0.23% 0.17%

Benign/borderline brain,cns 1 0.23% 2.65%

Buccal mucosa 1 0.23% 0.09%

Brain 1 0.23% 1.18%

Other respiratory 1 0.23% 0.22%

Tongue 1 0.23% 0.66%

Small Intestine 1 0.23% 0.46%

Testis 1 0.23% 0.47%

Total 429

Case Counts by Year 2003-2008Site 2003 2004 2005 2006 2007 2008

Lip 3 3 1 1 2 2

Tongue 3 4 2 0 1 1

Salivary glands 0 1 2 0 1 0

Gum & hard palate 2 3 1 0 1 0

Floor of mouth 4 1 3 2 0 0

Buccal mucosa 1 0 1 0 0 1

Oropharynx 1 1 1 4 3 10

Nasopharynx 0 0 0 2 0 2

Hypopharynx 1 2 4 1 0 1

Other oral cavity 0 0 0 0 1 0

Esophagus 6 5 6 8 10 8

Stomach 4 3 8 6 4 3

Small Intestine 4 4 4 1 2 1

Colon 37 31 30 34 37 42

Rectum/Anus 20 18 19 18 18 10

Liver 4 3 0 0 2 4

Gallbladder 3 3 5 2 1 0

Pancreas 7 7 14 7 8 11

Other digestive tract 2 2 3 0 1 0

Nasal cavities,sinuses,ear 1 2 2 0 1 0

Larynx 8 4 7 7 9 3

Trachea,bronchus,lung-small 14 13 15 11 20 13

Trachea,bronchus,lung-NSC 64 60 59 75 96 71

Other respiratory 0 1 0 1 3 1

Bone 1 0 0 1 0 0

Connective & soft tissue 2 1 1 1 2 2

Malignant melanoma 11 17 14 12 19 13

Other skin 0 4 1 1 2 0

Breast, female & male 58 59 47 55 76 61

Cervix 7 5 4 4 7 6

Endometrium (corpus uteri) 6 6 2 10 11 12

Ovary 3 5 5 9 3 3

Other female genital organs 4 6 5 9 8 8

Prostate 39 61 39 36 36 34

Testis 1 0 0 0 2 1

Other male genital organs 1 1 0 0 0 1

Bladder 16 22 15 15 18 15

Kidney 12 11 7 9 14 16

Other urinary organs 2 2 3 8 4 3

Brain 4 5 2 7 4 1

Thyroid 8 11 1 6 3 3

Other endocrine 0 0 0 1 0 0

Hodgkin's 3 2 3 2 1 3

Non-Hodgkin's Lymphomas 17 20 15 19 25 20

Plasma cell tumors 8 9 12 7 6 7

Lymphocytic leukemias 1 6 9 14 7 7

Myeloid leukemias 4 2 3 5 4 4

Other leukemias 0 1 0 1 0 0

Myeloprolif. & myelodysplas. 4 9 21 16 19 15

Other hematopoietic diseases 1 0 0 0 0 0

Other & ill-defined sites 0 0 1 0 0 0

Unknown primary 7 9 8 9 6 9

Benign/borderline brain,cns 0 4 4 4 0 1

Total 409 449 409 441 498 4298

89Mahr Cancer Center l 2009 Cancer Program Annual Report

Lymphoma is a type of cancer that begins in immune system cells called lymphocytes. Lymphoma

occurs when lymphocytes are in a state of uncontrolled cell growth and multiplication. There are two major types of lymphomas — Hodgkin’s lymphoma and Non-Hodgkin’s lymphoma.

The incidence rate of Non-Hodgkin’s lymphoma in the United States has almost doubled over the last 30 years, representing one of the largest increases of any cancer. Currently, NHL represents approximately four percent of all cancer diagnoses (four percent in males and four percent in females) in United States, being the fifth most common cancer in women and the sixth in men. In 2009, approximately 65,980 men and women (35,990 men and 29,990 women) will be diagnosed with Non-Hodgkin’s lymphoma in United States and 19,500 men and women will die of this disease.

In Kentucky, NHL is the fifth most common cancer with 840 cases (3.71 percent of all cancer diagnosis) diagnosed in 2008 and sixth leading cause of cancer mortality with 320 cases reported in 2008.

Twenty patients were diagnosed with NHL at Trover Regional Medical Center in 2008. NHL was the fifth most common cancer diagnosed at RMC in 2008 accounting for 4.7 percent of all cancer cases diagnosed. Sixty percent of these NHLs were aggressive (intermediate grade) and the rest of the 40 percent were indolent (low grade).

The cause of NHL is unknown in most of the patients, but certain risk factors associated with the development of NHL include:

• Toxins such as insecticides, pesticides and previous chemotherapy

• Infectious agents like HIV, EBV, HTLV-1, HCV and Helicobacter pylori

• Immunodeficiency disorders

• Use of immunosuppressive drugs especially after organ transplant

• Autoimmune diseases

There are several different types of Non-Hodgkin lymphomas. Multiple classification schemes have been employed for this disease over the years. The WHO classification, which incorporates immunophenotyping and genetic criteria in addition to morphological features, is widely used and accepted currently.

The clinical presentation of NHL varies depending upon the lymphoma subtype and the areas of involvement. Some NHLs have insidious onset with indolent course and lymphadenopathy wax and wane over years. Others behave more aggressively with rapidly growing mass and “B” symptoms (weight loss, fever and night sweats). Aggressive subtypes may result in death within weeks if not treated.

Less common presentations of lymphoma include skin rash, fatigue, bleeding, repeated infections or symptoms due to the involvement of “extra-nodal” tissues like bones, central nervous system, or gastrointestinal tract.

A biopsy is required for the diagnosis and classification of NHL. The evaluation of the biopsy specimen includes both an assessment of the appearance of tumor cells and pattern of lymph node involvement by tumor. Special stains (immunophenotyping) are used on the biopsy sample to confirm the diagnosis and to subtype most forms of NHL.

After the diagnosis of NHL has been established, the next step is to stage the disease. Staging defines the extent of involvement of lymph nodes and extra-lymphatic sites by NHL. Staging involves obtaining imaging studies such as a CT scan and a PET scan. Integrated PET/CT is generally preferred, when available. All patients with NHL also undergo a bone marrow aspiration and biopsy prior to the initiation of treatment as part of their staging evaluation.

9

Lymphoma Dr. Muhammad K. Siddique

10

There are four stages of NHL based on Ann Arbor staging system. Stage I refers to NHL involving a single lymph node region or extra-lymphatic region or site. Stage II refers to two or more involved lymph node regions or extra-lymphatic regions on the same side of the diaphragm. Stage III refers to lymph node involvement on both sides of the diaphragm or involvement of spleen. Stage IV refers to the presence of diffuse or disseminated involvement of one or more extra-lymphatic organs (such as liver, lung, bone marrow), with or without associated lymph node involvement.

The prognosis of NHL is determined by International Prognostic Index. The IPI is calculated based on the five risk factors, which include age more than 60, serum lactate dehydrogenase concentration greater than normal, ECOG performance status equal to or more than two, Ann Arbor clinical stage III or IV and more than one site of extranodal disease. The more the numbers of risk factors present the worse the prognosis.

The treatment of NHL depends on the histology, grade and stage of disease. Generally, surgery has a limited role in the treatment of lymphoma. The treatment of NHL usually involves systemic treatment and/or radiation therapy. Before employing any systemic treatment, full work up is done to make sure that patient has normal functioning of heart, kidneys and liver. Early stage low grade lymphomas may be curable with radiation therapy only. Watchful waiting is recommended for asymptomatic advanced

stage low grade lymphomas due to indolent course and incurable nature of disease. Systemic therapy is used for advanced stage low grade lymphomas only when they become symptomatic. Intermediate grade NHLs behave aggressively and almost always require treatment without delay. The treatment for intermediate grade lymphoma includes systemic therapy with or without radiation therapy. High grade lymphomas are very aggressive and are treated with aggressive systemic therapy similar to that used in the treatment of acute leukemias.

Systemic therapy for lymphoma includes both chemotherapy and immunotherapy. The selection of chemotherapy regimen is mainly dependent on type of lymphoma, but patient’s ability to tolerate certain chemotherapy regimen also is taken into consideration. The addition of immunotherapy to chemotherapy in certain lymphomas has been shown to significantly improve survival.

In case of recurrence or relapse, salvage chemotherapy followed by high dose chemotherapy and autologous stem cell transplant is the standard treatment in most lymphomas. However, allogeneic stem cell transplant also is employed depending on clinical settings.

Despite of increasing incidence of Non-Hodgkin’s lymphoma, mortality rate due to NHL is falling in the United States and the state of Kentucky, probably due to advancement in treatment.

11Mahr Cancer Center l 2009 Cancer Program Annual Report

Sarah E. Snell, MD - ChairmanGeneral Surgery/Surgical Oncology

William A. Logan, MD – ACoS LiaisonOtolaryngology – Head & Neck Surgery

Dr. Muhammad Siddique, MDHematology Oncology

Dr. Suresh Devineni, MDHematology Oncology

Satish Shah, MDRadiation Oncology

Justin Sedlak, MD Pathology

Craig Lundquist, MDDiagnostic Radiology

Richard Bauer, MDPathology

Darren Chapman, MDGeneral Surgery

Kerry Paape, MDCardiothoracic Surgery

William Crump, MDAssociate Dean, University of Louisville School of Medicine, Trover CampusFaculty, Family Practice Residency Program

T. Mark Stanfield, MDCardiothoracic Surgery

Will McColl, PhD, DABRMedical Physicist

Diana Jackson, RN, BSN, OCNDirector of Oncology ServicesCancer Program Coordinator

Jenifer Miller, RN, OCNClinical Trial Research Associate

Shari Walker, RT(T)Radiation Lead Therapist

Brandi Barnes, RNInpatient Oncology Services

Mary Ellington, RNHospice Assistant Director

Sheila Baker, RDFood & Nutrition

Rev. Bill McCannChaplain

Heather BlairACS Community Program Representative

Melanie Culbertson, RHIT, CPHQPerformance Improvement Manager

Margo Ashby, Pharm DDirector of Pharmacy

Judy Blue, CSWClinical Social Worker/Patient Representative

Joan Lang, MBARegional Coordinator, KY Cancer Program

Cy McCully, CSWCase Management

Rita CatesFinancial Counselor/ACS Ambassador/Community Rep.

Teresa Ford, CTRCancer Registry

Stacy Littlepage, CTRCancer Registry Coordinator

AD-Hoc members:Gerald Dysert, MD Obstetrics & Gynecology

Jack Hamman, MDThoracic Surgery

Harry Debandi, MDUrology

Stacey Beaven, RN, BSN, MSHA, NA-BCVP Nursing Services Department

Timothy DukesVP of Operations

2008-09 Cancer Committee

900 Hospital Drive l Madisonville, KY 42431 l 800.295.6247www.troverhealth.org