Understanding Cancer - Advisory · Understanding Cancer Mini Med School 1 ... Pediatric...
Transcript of Understanding Cancer - Advisory · Understanding Cancer Mini Med School 1 ... Pediatric...
Understanding Cancer Mini Med School
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The Advisory Board Company
Washington, D.C.
Presented by
Fabienne Moore, MD MPH
Senior Director, Talent Development
February 22, 2011
Mini Med School
• Facilitated Training Opportunities
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Cardiovascular
Care
TBD
Cancer
Care
Fabienne Moore, MD MPH
Today’s Module
Trauma
Care
Sean Benoit, MD
Roadmap for Discussion
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I. Cancer Biology
II. Diagnosing Cancer
III. Cancer Treatments
IV. Key Strategic Concerns
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I
Cancer Biology
A Cell that Goes Wrong
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Cancer Biology
Causes of Cancer
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Cancer Genetics
Familial (inherited)- Genetic Multi-factorial – Environmental,
Lifestyle
VS.
It only takes one mutation….
• BRCA gene mutations
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Cancer Biology
Basic Pathology
Heterogeneity of Cancer
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Tumor Sites
Lung & Bronchus
MelanomaHead & Neck
Pancreas
Breast (SEM)
Hematologic vs Solid Cancers
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Hematological Cancer
(e.g.. Leukemia)Solid Cancer (e.g. Soft
Tissue Sarcoma)
When is it Cancer?
• Epithelial cells (left) are tightly interconnected in sheets by numerous cell-cell interactions; their organization is determined by the basement membrane (lower left).
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Tumor Classification
Benign
Not invading surrounding
tissue or spreading to other
parts of the body.; may grow
but it stays put (in the same
place).
Malignant
Having the ability to invade
surrounding tissue and spread to
other locations throughout the
body
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Size Doesn’t Matter
Benign vs. Malignant Masses
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Benign Mass: Smooth-edged,
well-circumscribed,
encapsulated, homogenous
Malignant Tumor: invasive,
shaggy, ill-defined borders,
heterogenoous
Under the Microscope…
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Normal Kidney Benign Tumor
Renal Cell Carcinoma
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Stage 1: T1 N0 M0; T2 N0 M0 - Cancer has begun to spread, but is still in the inner lining
Stage 2: T3 N0 M0; T4 N0 M0 - Cancer has spread to other organs near the colon or rectum. It has not reached lymph nodes.
Stage 3: Any T, N1-2, M0 - Cancer has spread to lymph nodes, but has not been carried to distant parts of the body
Stage 4: Any T, any N, M1 - Cancer has been carried through the lymph system to distant parts of the body. The most likely organs to
experience metastasis from colorectal cancer are the lungs and liver.
Tumor Classification
After Biopsy, the tumor may be
more accurately classified in the
following method:
By Tumor, which describes the
invasion of cancer cells into an
immediately surrounding the
tumor site. Graded T to T4
By Lymph Node involvement.
Graded NX to N1
By Metastasis, or distal spread
of cancer cells to other tissues.
Graded PM1c-M1c
By Surgical Margins:
Graded as R
Staging: How Far Has it
Progressed?
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Metastases Revisited
Local Cancer (e.g.
Stomach Cancer)
VS.
Metastases
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II
Diagnosing Cancer
The Big Four
Tumor SiteIncidence
Rate*% of Cancer
Mortality Incidence Rate% of Cancer
Mortality
Breast -- -- 120.4 15%
Lung 80.5 31% 54.5 26%
Prostate 156.9 10% -- --
Colorectal 52.7 8% 39.7 10%
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U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based
Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National
Cancer Institute; 2010. Available at: www.cdc.gov/uscs.
2007 Estimated New Cases & Cancer Deaths in US
The Rest, 2007 Estimated Deaths
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Men
Pancreas 6%
Leukemia 4%
Non-Hodgkin Lymphoma 3%
Esophagus 4%
Liver and intrahepatic bile duct 4%
Kidney 3%
Other sites 27%
Women
Ovary 6%
Pancreas 6%
Leukemia 4%
Non-Hodgkin Lymphoma 3%
Uterine corpus 3%
Multiple myeloma 2%
Brain/nervous system 2%
Other sites 23%
Source: American Cancer Society, 2007.
Pediatric Epidemiology
Site Male Female Total
Leukemia 5.3 4.5 4.9
Brain 3.4 3.1 3.2
Non-Hodgkinslymphoma
1.1 0.6 0.9
Kidney & renal pelvis
0.8 0.8 0.8
Soft tissue 1.0 1.1 1.0
All sites 15.8 14.0 14.9
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Cancer Incidence Rates* in Children, 0-14 Years
*per 100,000 age-adjusted to the 2000 US standard population
Source: American Cancer Society, 2007.
Pediatric Epidemiology
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Trends in Survival, Children 0-14 Years
Age
0-4
5-9
10-14
Year of Diagnosis 5 Year Relative Survival Rates
57.31974-76
1992-99 80.2
1974-76
1992-99
1974-76
1992-99
58.5
78.3
58.9
79.9
Source: American Cancer Society, 2007.
How Is Cancer Diagnosed?
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Diagnosis: The process of identifying a disease based on signs
and symptoms
Signs Symptoms
•Shortness of
breath
•Chest pain
•Loss of appetite
•Inflammation of
lungs (pneumonia)
•Wheezing
•Hemoptysis
(bloody, coughed-
up sputum)
•Weight Loss
•Cough
Preemptively Seeking Out Disease
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Mammography: Low dose x-ray system used to screen breasts
for early signs of cancer
Screening Technologies
PSA Test: Blood test which measures the amount
of prostate-specific antigen in the blood
Colonoscopy: visual inspection of the colon to screen for
polyps or other masses
The Next Screening Frontier
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Virtual Colonoscopy: Also known as CT colonography, uses
computed tomography (CT scan) to generate unique 2- and 3-D
images of the colon to identify cancerous polyps
Breast MRI: high-resolution MRI provides increased sensitivity
for breast cancer screening in a radiation-free screening modality
Ruling In (or Out) Cancer
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Diagnostic Technologies
Biopsy PET
Positron emission
tomography (PET) is
used to detect
radiation from
emission of positrons
in the body. Most
commonly used to
detect cancer or
examine effects of
cancer therapy on the
body
A biopsy is a
procedure in which a
cylinder of tissue is
removed from the
body and tested under
a microscope for signs
of cancer
Types of Oncologists
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Medical Oncology
Radiation Oncology
Interventional
Oncology
Cancer Physicians
Internists, certified by the American Board
of internal medicine, who use medical and
chemotherapeutic means to treat cancer
Radiation oncologists, certified by the
American College of Radiology, specialize in
radiation treatment of cancers
Surgical oncologists, certified by the
American Board of Surgery, are trained in
several types of surgical treatments,
including biopsy, tumor staging, and tumor
removal
Surgical Oncology
Interventional Radiologists—specializing in
image guided, minimally invasive
interventions—with a distinct focus on
treating cancer cases
Other Important Physicians
• Diagnosis and Treatment
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Radiologists Pathologists Other Specialists
• Thoracic Surgeons
• Urologists
• Pulmonologists
• Primary Care
Physicians
• Physiatrists
• Almost every doctor
deals with cancer
Tumor Boards the Gold Standard• Multidisciplinary approach brings all clinicians to the table
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Hepatocellular
Carcinoma
PatientRadiation
Oncologist
Interventional
Radiologist Radiologist
Transplant
Surgeon
Primary Care
Physician
Transplant
Coordinator
Medical
Oncologist
Psychologist
Hepatobiliary
Surgeon
Introducing Gary Hetch
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Case Study
Gary Hetch, 55• Database administrator at small, IT firm in FL
• Wife, Brenda, and three children, 28, 23, and 18
• Makes appointment at his physician’s office after
experiencing blood in urine and pain/stiffness in his
back and hips
• Family history: Mother died of breast cancer at
age 76
• No previous screening tests
Was Gary at risk?
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Environmental
FactorsGenetic Factors
•Long-time follower of
Atkin’s Diet, high-
protien, high-fat
•Selenium-, lycopene-,
and fiber-deficient diet
(Mom would have
disapproved)
•IT: sedentary job
•Family history of breast
cancer (mother and
grandmother)
Gary’s path to the hospital
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Doctor’s Office Specialist’s Office Hospital
Gary shows up
at his doctor’s
office,
complaining of
blood in urine
and stiff hip/back
Gary is referred
to urologist for
additional
testing, PSA
elevated
Gary’s urologist
schedules
prostate biopsy
at hospital
Biopsy confirms
prostate cancer
Staging and Treatment
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Dr. Feretti
Radiation Oncologist
• Imaging tests reveal metastases to spine, confirming
stage IV prostate cancer
• Gary works with Feretti, radiation oncologist, to establish
course of care
•5 treatments per week for 7 weeks at hospital’s
outpatient radiology center
•Post-treatment, Dr. Feretti, Gary, and his primary care
physician will work together to monitor progress with PSA
testing
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III
Cancer Treatments
Wide Range of Treatment Options
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Oncology Treatment Technology Benchmarking by Sub-Service Line
Sub-Service
Line
Standard Offering Advanced Offering Progressive Edge
Radiation
Oncology
Interventional-
Surgical
Oncology
Medical
Oncology
Diagnostic
Imaging
IMRT IGRT
HDR
BrachytherapyLDR
Brachytherapy
Extracranial
SRSProton
Beam
Therapy3D-CRT
Cryoablation
Robotic
Surgery
RFA
VMAT
PET/CT1.5T Fixed-
Site MRI 7T MRI
3T MRI
SPECT/CT
Film MammographyFull-Field
Digital MammographyBreast
Tomosynthesis
Digital X-Ray
Tomosynthesis
Ultrasound
4-Slice
CT
16-Slice CT 64-Slice
CT
Next-Generation CT
Intracranial
SRS IORT
2D-CRT
Cryoablation
Open
Resection
Laparoscopic
Resection
Single Port
Access SurgeryMRgFUS
Transarterial
Chemoembolization Selective Internal
Radiation Therapy
(SIRT)
Hyperthermia
Breast
MRI
Virtual
Colonoscopy
Chemotherapy Oral
Chemotherapy
Targeted
Therapies
Vaccine Therapy
Genetic
Counseling
Genetic Testing
SPECT
Gene Therapy
Hormone
Therapy
CT Lung
Screening
Breast-Specific
Gamma Imaging
Positron Emission
Mammography
25th Percentile 50th Percentile 95th Percentile
Treatment Types
37Chemo (Medical) Radiation Surgery
Hormone Therapy Biologic Therapy
Despite Innovation, Surgery Still Reins Supreme
Prevalence of Use of Primary Treatment Approaches, by Tumor Site
Treatment
ModalityProstate NSCLC SCLC Breast Colon Rectal Bladder Cervical Uterine
Renal
PelvisMelanoma
Surgery X X X X X X X X X X
RT X X X X X X X
Chemotherapy X X X X X
Hormone
TherapyX X X
Immunotherap
y
“X” denotes use of particular therapy in 20 percent or more of primary treatments
Surgery
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Surgical Oncology
Image: Colon Cancer Surgery
Chemotherapy
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Chemotherapy
Clinical Trials• Clinical Trials for Chemotherapy Treatments
• Taking Part in a Trial
• Understanding Cancer Research Trials
• Duration of Research
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Radiation Therapy
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Radiation Therapy
Stereotactic Radiosurgery
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Proton Beam Therapy• The most expensive, resource intensive medical technology
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Easing Side Effects
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Supportive Care
Anemia Drugs
•Epoetin
•Procrit
•Aranesp
Neutropenia Drugs
•Neulasta
•Neupogen
Antiemetics
•Emend
•THC?
Complementary/Alternative Medicine
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CAM
Acupuncture ChiropracticHomeopathy
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IV
Key Strategic Concerns
Cost of Cancer Care
Source: American Cancer Society, available at: http://www.cancer.org/cancer/cancerbasics/economic-impact-of-cancer, accessed August 23 2010 ; Milliman Client Report, “Cancer Patients receiving Chemotherapy: Opportunities for Better Management” available at: http://publications.milliman.com/research/health-
rr/pdfs/cancer-patients-receiving-chemotherapy.pdf, accessed August 23 2010 ; Oncology Roundtable interviews and analysis.
Rapid Rise in Oncology Costs in the Spotlight
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$111,000
Average drug costs per chemotherapy patient
$22,353
Average cost of care of patient receiving chemotherapy
20082004
$72B
$93B
29% increase
Essential to Streamline Care Process to Manage Future Demand
Cancer Care Ripe for Reform
Source: Oncology Roundtable interviews and analysis.
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Demographics Complexity of Care
Variability in Utilization and Outcomes
Cost Burden
Poor Care Coordination
Clinical Innovation
Provider Shortage
Baby boomers reaching period of
highest cancer incidence
Increasing multi modal therapy;
growing survivor needs
Significant variation in treatment pattern and outcomes, lack of
comparative data to inform treatment decisions
Sky rocketing cost of care per patient
Numerous transitions across providers, sites of care
Emergence of new, costly treatments (e.g., proton beam
therapy, targeted therapies
Forecast shortage of medical oncologists.
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ABC Resources
I. Oncology Roundtable
II. Technology Insights
III. Innovations Center
ABC Offerings Impact Oncology Services
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2010-2011 Oncology Roundtable Meeting Series
Transforming Cancer Care• Assessing health care reform’s impact on the delivery of cancer care
• Organizing for accountable care
• Implementing clinical pathways to drive care standardization
Elevating Referral Strategy• Identifying key drivers of physician preference
• Leveraging technology to improve communication with referring
physicians
• Enhancing outreach to community physicians
Delivering on the Promise of Patient-Centered
Care• Expediting access to care
• Optimizing patient navigation models
• Organizing services to meet survivors’ needs
• Delivering on service excellence
Additional Resources
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For More Information
NCI
American Cancer Society
ASTRO
ASCO
Oncolink
MD Anderson
NCCN
Oncology Roundtable: Allison Cuff, x5713
Innovations Center: Joe McCaffrey, x6208
Technology Insights: Matt Garabrant, x6341
Or call me with any clinical issue: Lisa
Bielamowicz, x6340