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C A N C E R P R O G R A M
A N N U A L R E P O R T
Cancer Program Annual Report
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TABLE OF CONTENTS
Cancer Committee Chairman Welcome 5
Cancer Committee 6
Cancer Program Highlights 8
Performance Improvement Initiatives 12
Program Goals 13
Clinical Goals 13
Cancer Registry 14
Focus Report on Lung Cancer 20
Acknowledgments 25
References 25
Directory of Services 26
Glossary Of Terms 27
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2018 PIH HEALTH HOSPITAL - WHITTIER CANCER COMMITTEE CHAIRMAN WELCOME
The 2018 PIH Health Hospital - Whittier Cancer Center Annual Report highlights our cancer services and the impact we have made in our community. Since 1987, the PIH Health Hospital - Whittier Cancer Program has been accredited by American College of Surgeons Commission on Cancer (CoC), which ensures that we provide high-quality cancer care. One of the requirements of CoC accreditation is having a Cancer Committee to oversee the program. Our committee meets regularly to ensure our patients receive only outstanding care. The Cancer Committee frequently reviews trends in our cancer diagnosis and staging as well as treatment outcomes to ensure we are comparable or better than similar programs throughout the United States. The committee is continuously looking for opportunities for improvement not only in the treatment of cancer but in the patient experience. They also create, review and recommend ways to improve education and awareness on cancer prevention screenings. This year, the program experienced a myriad of successes which included an increase in the number of breast, colon and lung cancer screenings. PIH Health also offered a variety of cancer awareness lectures. In this report, you will see more on our outcomes and the types of cancer treated, as well as a full review of the impact of lung cancer sceening authored by the Chairman of Radiology, Dr. Daniel Saket MD.
Respectfully,
Dustin E. Stevenson DOCancer Committee ChairmanInfusion Center Medical Director
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The PIH Health Hospital - Whittier Cancer Committee is a multi-disciplinary team composed of medical staff members from diagnostic and therapeutic specialties, administrative staff and allied health professionals involved in the care of cancer patients. The committee members work together to provide the highest quality of care to cancer patients and play a key role in the success of PIH Health.
Physician Members
Anthony Britto MDPlastic Surgeon
Armen Gregorian MDColorectal Surgeon
Brent Gray MDAssistant Vice President of Medical Affairs (VPMA)/OB/Gyn
Dustin E. Stevenson DOHematologist/Medical Oncologist/Chair, Cancer Committee
Edwin Lin MDHematologist/Medical Oncologist
Jack Freimann MDHematologist/Medical Oncologist
Jeffrey Yuen MDRadiation Oncologist
Kennith Thompson MDCo-Medical Director Breast Health Center/Cancer Liaison Physician/General Surgeon
Kimberly Bickell MDCo-Medical Director Breast Health Center, Diagnostic Radiologist
Lily Wang MDDiagnostic Radiologist/Co-Medical Director, Breast Health Center
Lisa S. Wang MDHematologist/Medical Oncologist
Mark Odou MDSurgeon
Merrill Shum MDHematologist/Medical Oncologist
Nadeem Chishti MDPulmonologist
Nathan Honda MDCancer Program Medical Director/Cancer Liaison Physician/Pathologist
Robert Kleinman MDDiagnostic Radiologist
William Kurohara MDQuality Control Coordinator of Registry Data/Radiation Oncologist
CANCER COMMITTEE 2018
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Non-Physician Members
Andrea Allsup MSWSocial Worker/Psychosocial Activity Coordinator
April Hopper CTRCancer Data Specialist/Conference Activity Coordinator
Ashley MillhouseSystem Manager, American Cancer Society
Carla Guess RN CBCN CB BNOncology Nurse Navigator, Breast Health Center
Claire McClafferty LCSWPalliative Care
Chantel K. Tanuvasa-Strotman MSWSocial Worker/Psychosocial Activity Coordinator
Dan Ogletree MSWPalliative Care
Debbie McKnight RN MSNAdministrative Director, Med-Surgical Services/ Administrator
Gayle Madden-Mathes RN OCNLung Screening Program Nurse Navigator
Genevieve Taguinod RN MSN NPManager, Infusion Center
Graciela Montes RNDirector of Group Operations, Administration
Ivonne Munoz RN BSNDirector, Breast Health Center
Kathy Seymour RN BSN OCNOncology Nurse Navigator, Cancer Program
Kristine Cooper CTRCancer Data Specialist/ Conference Activity Coordinator
Lorraine DeGiacomo RN BSN OCNManager, Radiation Oncology
Lucinda Place RN MSNAdministrator, Quality Management
Lynze Ruvalcaba RN BSN OCNClinical Director, Oncology Unit/Infusion Center
Maribel Ordorica RNPractice Manager, PIH Health Physicians Oncology Group
Marie Cruz GarciaCancer Registry
Nicole M Terrazas RN MSN CNSClinical Nurse Specialist, Quality Management
Perry EbeltoftVice President, Ancillary Services
Raquel Varella PT/CLTPhysical Therapist, Lymphedema Program
Reanna Thompson RN MSN CNO COOChief Nurse Officer, Chief Operating Officer/ Administrator
Regina Christ RN MSN NPPalliative Care
Rosie Drulias RN BSN PHN CCRPClinical Trials/Clinical Research Activity Coordinator
Sarah Merkle RN MSN AOCNSClinical Director, Cancer Program / PI Coordinator
Shelly Hart PTA-CLTPhysical Therapist Lymphedema Program
Sue Jervik RN BSNPain Management Educator
Tammy Neu RNClinical Director, Hospice
Thia Le RDManager, Clinical Nutrition
Vanessa IvieDirector, Community Benefit and Community Health
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The PIH Health Hospital - Whittier Comprehensive Community Cancer Center provided a number of services to cancer patients in our community and beyond.
PIH Health partnered with Vogue Wigs to facilitate a wig event for cancer patients and survivors who have experienced hair loss or thinning from cancer treatment. Over 100 wigs were provided on April 14, 2018 at no cost to the patient.
The National Comprehensive Cancer Network (NCCN) distress tool was provided to all appropriate patients at PIH Health undergoing cancer treatment in the Infusion Center and Radiation Oncology.
Survivorship Care Plan delivery continued to be a priority throughout 2018. The Survivorship Care Plan summarizes the patient’s diagnosis, treatment plan and follow-up information and is essential for the continued journey into survivorship for cancer patients.
The PIH Health Hospital - Whittier Radiation Oncology center was reaccredited by the American College of Radiology.
Cancer Survivors were invited to learn about nutrition, through treatment and beyond, at a survivorship workshop held in July 2018.
On June 1, 2018, PIH Health honored all cancer survivors by celebrating National Cancer Survivors Day. Gifts and information targeted for survivors were distributed throughout the day.
2018 CANCER PROGRAM HIGHLIGHTS
Aimee Yalung, Vogue Wigs fitting cancer survivor
Sarah Merkle, Kristine Cooper and Gayle Madden-Mathes celebrating National Cancer Survivor’s Day
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Complimentary Therapy
The Mind Body & Spirit Workshop Series was offered during the course of the year to support cancer patients throughout their journey. Studies have shown patients who manifest a strong spiritual connection or practice tend to be more positive and have better coping strategies. The workshop helps connect patients with their spirituality to move through life’s challenges with greater peace and awareness.
Yoga classes continue to be provided to our cancer survivors. These classes help patients reconnect with their bodies through gentle yoga designed for those facing or recovering from the challenges of cancer or other illness.
Clinical Trials
In 2018, clinical trials continued to be an area of growth for PIH Health Hospital - Whittier. Offering clinical trials allows us to provide new approaches to treating and managing cancer.
PIH Health is affiliated with SWOG (formerly Southwest Oncology Group), a National Cancer Institute-supported organization that designs and conducts publicly funded clinical trials. Through this affiliation, we have 14 clinical trials actively accruing for various stages of breast, lung, kidney, colon and rectal cancers. Most recently, two clinical trials were opened for triple negative breast cancer. A trial for patients with high-risk kidney cancer was also initiated in 2018.
Mariposa Boutique
The Mariposa is a unique wellness boutique that helps patients return to a full and active life after surgery by introducing them to a wide range of products and services. Staff members include Certified Mastectomy Fitters who provide consultations on special breast prostheses and bras, and specialize in fitting lymphedema sleeves and compression medical wear. Women may obtain information on lymphedema, hospital and local support groups, and internet-based resources. Other items available for purchase include scarves, hats, wigs and jewelry. The services at Mariposa enable breast cancer patients and survivors to feel confident and beautiful.
Cancer Screening and Early Detection (Commission on Cancer Standard Standard 4.2)
PIH Health is focused on wellness and illness prevention. Cancer screenings are designed to detect cancer early and decrease the number of late stage disease cases. In 2018, there was an increase in the number of patients screened for breast, colon and lung cancer. All screening programs are consistent with evidence-based guidelines.
Kathy Seymour RN BSN OCN, facilitator of Mind, Body & Spirit Workshop Series
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• Breast Cancer Screening
• Performed with mammography
• Over 16,000 screening mammographies performed
• 4 percent increase
• Colon Cancer Screening
• Performed via colonoscopy
• 1,850 screening colonoscopies performed
• Lung Cancer Screening
• Performed with low-dose computed tomography (CT)
• 360 screening CTs performed
• 19 percent increase
Community Outreach and Education on Cancer Prevention (Commission on Cancer Standard Standard 4.1)
The Cancer Committee worked with multiple internal departments and outside organizations to provide quality cancer care within our organization and throughout the community. PIH Health offered numerous community outreach and educational activities during 2018, including:
• Colon Cancer Awareness
• Melanoma-Skin Cancer Awareness
• Breast Cancer Awareness
• Cancer Survivorship Workshops
• Smoking Cessation Workshop
PIH Health and American Cancer Society (ACS) offered numerous support groups including:
• Breast and Women’s Cancer Support Group
• Journey Through Cancer Support Group
• Life After Cancer
• Grief Recovery
• Look Good, Feel Better
• Healing After Loss
• I Count Too
• I Can Cope
Oncology Resource Center
The Oncology Resource Center and Wig Bank are available for patients and their family members to access educational material and resources. Wigs and head coverings gifted to these women provide dignity and compassion during their journey. In 2018, 178 wigs and head coverings were provided to women going through cancer treatment. The resources of the wig bank are made possible by the generosity and support of donors in our community.
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Barriers to Care: Helping Our Patients Every Step of the Way (Commission on Cancer Standard Standard 3.1)
Our recent Community Health Needs Assessment (CHNA) identified that financial and insurance issues were among the top concerns for patients in our service area. In an effort to address this perceived barrier to care, “Navigating the Health Care Maze”, a class that addresses financial and insurance issues, was offered to cancer patients. The class was offered eight times throughout the year and addressed topics such as considerations for insurance coverage, understanding medical bills, and other health management tips.
Sarah Merkle, Patricia Dudley, Annette Atwood, and Amy Fitzgerald, with Rio Hondo College Students making a donation to the PIH Health Wig Bank
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Reducing Central Line Blood Stream Infections for Hospitalized Oncology Patients
Many cancer patients require a central venous access device or central line to receive treatment or supportive care. One of the most common complications of a central line is a blood stream infection. The inpatient oncology unit at PIH Health Hospital - Whittier noticed a rise in the Standardized Infection Ratio (SIR) for central lines. Through implementation of a standard process requiring two Registered Nurses be present for all port accessing, dressing changes and blood draws, the unit decreased their SIR from 2.49 to 0.90.
Nurse Assessment for Chemotherapy Induced Peripheral Neuropathy
Some chemotherapy medications cause peripheral neuropathies such as numbness in the hands or feet. An assessment for these side effects is performed prior to a cancer patient receiving a dose of medication that may cause this side effect. Standardization of this assessment was not well established. As a result, the PIH Health Hospital - Whittier Infusion Center optimized the existing neurovascular assessment tool to better assess and document neuropathy.
PERFORMANCE IMPROVEMENT INITIATIVES ESTABLISHED IN 2018
COMMISSION ON CANCER STANDARD 4.8
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Design a Disaster Relief Plan for PIH Health Oncology
In light of the environmental tragedies that occurred throughout the country in 2018, the PIH Health Cancer Committee designed a disaster relief plan for PIH Health Oncology to help us deliver cancer care during a natural disaster. The policy outlines the triage process in the event of an internal or external disaster.
Improve the care of patients receiving High Dose Radiation (HDR) through nurse education and implementation of standardized orders.
Occasionally patients with cervical cancer need to be admitted to the inpatient oncology unit for HDR. When this occurred in the past, the nurses did not feel prepared to manage the patient. The clinical goal for 2018 was to improve the care of patients receiving HDR through nurse education and implementation of standardized orders. All inpatient oncology nurses received education on management of patients receiving HDR. A computer-based test will be administered to the staff annually to ensure sustained competency.
PROGRAM GOAL ESTABLISHED IN 2018
CLINICAL GOAL ESTABLISHED IN 2018
COMMISSION ON CANCER STANDARD 1.5
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Established in 1987, the Cancer Registry is an essential component of the PIH Health Hospital - Whittier Comprehensive Community Cancer Program. Our cancer database management system is designed to monitor all types of cancers diagnosed and/or treated at PIH Health and is a critical element in the evaluation of cancer care. Demographic information, cancer type, treatment and follow-up data are collected on each cancer patient by the registry staff, who are specially trained in the field of oncology data management. In 2018, the Cancer Registry database included data on 37,495 cases.
Cancer Statistics
CANCER REGISTRY
In 2017, 1,251 patients were diagnosed or received cancer care at PIH Health. These cases were diagnosed through the PIH Health service area. (Figure 1)
The most commonly diagnosed cancers detected and treated at PIH Health were compared to California cancer incidence and ranked according to frequency. Cancer incidence by gender at PIH Health was 536 males and 715 females. The incidence of breast cancer is higher at PIH Health compared to California rates. (Table 1)
536 Males and 715 Females — Totaling 1,251
MALE FEMALE
Cancer Site #pts PIH Health #pts US Cancer Site #pts PIH Health #pts US
Prostate 92 17% 180,890 21% Breast 219 31% 266,120 30%
Lung/Bronchus 66 12% 121,680 14% Lung/Bronchus 82 11% 112,350 13%
Colon & Rectum 57 11% 75,610 9% Colon & Rectum 43 6% 64,640 7%
Kidney & Renal Pelvis 41 8% 42,680 5% Uterus 42 6% 63,230 7%
Lymphoma 33 6% 46,570 5% Lymphoma 35 5% 36,610 4%
Table 1
Figure 12017 Geographic Distribution of Caseload 1,019 Analytic Cancer Patients seen at PIH Health
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CLASS OF CASE SEX* STAGE AT DIAGNOSIS*
PRIMARY SITE Cases A N/A M F 0 I II III IV UNK NA
ALL SITES 1251 1019 232 536 715 101 291 164 122 161 74 105
HEAD & NECK 22 18 4 17 5 0 3 3 3 5 4 0
Tongue 2 2 0 1 1 0 2 0 0 0 0 0
Salivary Gland 4 4 0 1 3 0 1 1 1 0 1 0
Floor of Mouth/Gum/Other 3 3 0 3 0 0 0 0 0 2 1 0
Nasopharynx 6 4 2 5 1 0 0 1 1 1 1 0
Tonsil 4 4 0 4 0 0 0 1 1 2 0 0
Hypopharynx/Oropharynx 2 1 1 2 0 0 0 0 0 0 1 0
Pharynx/Other Oral 1 0 1 1 0 0 0 0 0 0 0 0
DIGESTIVE SYSTEM 263 221 42 132 130 7 32 39 46 48 47 2
Appendix 3 3 0 1 2 1 2 0 0 0 0 0
Esophagus 11 9 2 7 4 1 0 1 1 3 3 0
Stomach 25 19 6 12 12 0 1 2 3 5 8 0
Small Intestine/Lg Intestine 31 15 16 11 20 0 2 3 0 5 5 0
Colon/Rectum/Recto sigmoid/Hepatic Flexure/Cecum 92 86 6 52 40 5 18 22 29 7 4 1
Anus/Anal Canal/Anorectum 4 4 0 2 2 0 1 2 1 0 0 0
Liver 30 24 6 18 12 0 1 3 5 1 13 1
Gallbladder/Bile Ducts/other 25 23 2 7 18 1 5 1 2 10 4 0
Pancreas 42 38 4 22 20 0 5 6 6 17 4 0
RESPIRATORY/ INTRATHORACIC 152 124 28 69 83 7 46 10 12 47 1 1
Nose/Nasal Cavity/ Sinus/Mid Ear 1 0 1 1 0 0 0 0 0 0 0 0
Larynx/Trachea/Mediastinum/ Pleura other Respiratory 2 2 0 2 0 0 0 1 0 1 0 0
Mesothelioma 1 0 1 0 1 0 0 0 0 0 0 0
Lung/Bronchus 148 122 26 66 82 7 46 9 12 46 1 1
BLOOD & BONE MARROW** 105 70 35 50 55 0 7 10 8 15 5 25
Leukemia 16 12 4 10 6 0 0 0 0 0 0 12
Multiple Myeloma 21 12 9 7 14 0 0 0 0 0 0 12
Non-Hodgkin Lymphoma 64 42 22 32 32 0 7 7 8 14 5 1
Hodgkin Lymphoma 4 4 0 1 3 0 0 3 0 1 0 0
SOFT TISSUE/HEART/BONE 13 7 6 10 3 0 1 1 2 0 3 0
SKIN 36 31 5 20 16 4 12 8 4 2 1 0
Melanoma of Skin 35 31 4 20 15 4 12 8 4 2 1 0
Other Skin/Kaposi Sarcoma 1 0 1 0 1 0 0 0 0 0 0 0
BREAST 220 193 27 1 219 47 84 47 8 7 0 0
FEMALE GENITAL 98 81 17 0 98 3 38 11 17 10 2 0
Cervix Uteri/Cervix Insitu 14 7 7 0 14 0 2 1 3 1 0 0
Corpus Uteri/Uterus NOS 48 46 2 0 48 0 29 5 5 7 0 0
Ovary 25 20 5 0 25 0 6 4 7 1 2 0
Vulva/Vagina/Other 11 8 3 0 11 3 1 1 2 1 0 0
MALE GENITAL 103 67 36 103 0 1 20 24 8 12 1 0
Prostate 92 56 36 92 0 0 13 24 7 12 0 0
Testis/Penis/ Other 11 10 1 11 0 1 7 0 1 0 1 0
URINARY 108 101 7 75 32 32 33 9 10 10 7 0
Bladder 52 50 2 43 8 26 12 4 1 6 1 0
Kidney and Renal Pelvis 52 48 4 29 23 5 21 4 8 4 6 0
Ureter/Other Urinary 4 3 1 3 1 1 0 1 1 0 0 0
EYE & ORBIT 2 1 1 2 0 0 0 0 0 0 0 1
BRAIN & OTHER CNS 38 32 6 14 23 0 0 0 0 0 0 32
THYROID & ENDOCRINE 42 37 5 14 28 0 16 2 4 7 0 8
OTHER 49 36 13 27 22 0 0 0 0 0 0 36
The Primary Site Distribution Table details PIH Health Hospital - Whittier’s 2017 cancer experiences by site, age, gender and stage of disease at diagnosis. (Table 2)
*Stage reflects analytic cases **AJCC Stage not applicable NA = Non-applicable UNK = Unknown Stage
Table 2
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Number of New Cancer Cases
Figure 2 depicts the number of newly diagnosed cancer cases added to the Oncology Registry from 2007 to 2017. These cases are categorized into three groups: new cancer cases for the year 2017; cases diagnosed and treatment given; and those diagnosed elsewhere, but received initial treatment at PIH Health.
Stage at Diagnosis for New Cases in 2017
The stage of disease at the time of diagnosis plays a vital role in the prognosis and treatment of a cancer patient. In 2017, 32 percent of all newly diagnosed patients were in early stage at diagnosis (in-situ or Stage I), 13 percent were Stage II, 10 percent were Stage III, 15 percent were Stage IV, 12 percent were not applicable for staging (NA) and 19 percent were classified as unknown stage at time of diagnosis. (Figure 3)
Figure 2
Year 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Diagnosed & Treated 820 921 799 916 1032 936 959 1077 1060 1035 1019
All New Cases 611 770 642 747 884 786 807 917 920 941 942
Treated Only 151 151 157 169 148 150 152 160 140 129 89
Num
ber o
f Cas
es
275
550
825
1100
Year of Diagnosis
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
151 151 157 169 148 150 152 160 140 12989
611
770
642
747
884
786 807
917 920 941 942
820
921
799
916
1,032
936959
1,077 1,0601,035 1,019
Diagnosed & TreatedAll New CasesTreated Only
"1
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Age Distribution at Diagnosis in 2017
Sixty-six percent of patients were between the ages of 60 and 89 at diagnosis. The median age was 68 years. (Figure 4)
Figure 4
Figure 3Stage at Diagnosis1,019 Analytic Cases
Stage at diagnosisIn Situ 8%Stage I 24%Stage II 13%Stage III 10%Stage IV 15%NA 12%Unknown 19%
Perc
ent
0%
6%
12%
18%
24%
30%
Stage at Diagnosis
In Situ Stage I Stage II Stage III Stage IV NA Unknown
19%
12%
15%
10%
13%
24%
8%
2
Age 2-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90 & upPercent of Cases 5% 1% 3% 7% 13% 23% 27% 16% 4%
Perc
ent o
f Cas
es
0%
10%
20%
30%
40%
Age
2-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90 & up
4%
16%
27%
23%
13%
7%
3%1%
5%
3
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Physicians Who Presented and Participated in Case Presentations at Cancer Conferences in 2018
Daniel Akhavan MDKimberly Bickell MDAlok Bhatt MDJohn Britto MDLeo Buxbaum MDAlfred Castellanos MDNadeem Chishti MDDhand Sabeen MD Jacques Dorce MDJoel Garris MDArmen Gregorian MDJack Freimann MDNathan Honda MDC. Rodger Hughes MDNassr Hussein MDSamuel Im MDMaureen Jensen MDNeil Klein MDRobert Kleinman MDNanette Kovash DOJames Kuo MDWilliam Kurohara MDJason Lai MDEdwin Lin MD
William MacDonald MDSanchayeeta Mitra MDMark Odou MDChristie Pang MDJoseph Park MD Yong Park MDMillicent Rovello MDDaniel Saket MD Kiumars Saketkhoo MDDennis Sargent MDMukesh Shah MD Merrill Shum MDJoomee Shim MDDustin Stevenson DOEddie Thara DOKennith Thompson MDEduardo Tovar MDMiguel Velez MDLilly Wang MDLisa S. Wang MDGerald Yoon MDBrian Yue MDJeffrey Yuen MDScott Yun MD
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2018 Breast, Lung & Multidisciplinary Cancer Conferences and Lecture Summary
Cancer conferences provide a multidisciplinary, patient specific, treatment-planning, consultative service for patients and their managing physicians. The conferences offer a forum for discussing various treatments options and assist in determining the most appropriate patient management plan.
Cancer Site Presented Number of Cases Presented
Breast 185
Lung 135
Pleura 5
Colorectal/Anus 30
Stomach 10
Skin/Melanoma 4
Pancreas/Bile Duct 14
Ovary/Fallopian Tube 3
Corpus Uteri/Vulva/Endocervical/Vagina 10
Lymphoma 7
Unknown Primary 12
Gall Bladder 2
Head & Neck 1
Soft Tissue 2
Thyroid 3
Leukemia/Myeloma 4
Liver 6
Kidney 9
Brain 9
Esophagus 4
Prostate 3
Spine 1
Small Intestine 2
Testis 2
Pyriform sinus 1
Bladder 2
Retroperitoneum 1
Thymus 1
Vocal Cord 1
Additionally, two CME lectures were offered:
• Management of ER Positive Metastatic Breast Cancer Sara Hurvitz MD University of California, Los Angeles, CA April 10, 2018
• A System Based Patient Centered Approach to HER-2 Positive Breast Cancer Joyce A. O’Shaughnessy MD The US Oncology Network, Dallas, TX September 18, 2018
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Introduction
According to the American Cancer Society, in 2019 there will be 228,150 new cases of lung cancer in the United States. Lung cancer is the leading cause of cancer-related death in both men and women. An estimated 142,670 deaths will occur in 2019 due to the disease, which is greater than the next three causes (colon, breast and pancreatic) combined. One in 15 people will develop lung cancer in their lifetime.
Risk Factors
The primary risk factor for lung cancer is tobacco use, which is responsible for 90-95 percent of overall cases. Additional risk factors include family history, COPD, pulmonary fibrosis, asbestos exposure, variety of dust and other toxic exposures, and personal history of another cancer. Two-thirds of cases are seen in people aged 65 and over. Women (especially East Asian) account for the majority of never smokers with lung cancer, many of whom harbor a specific EGFR mutation.
Screening
Lung cancer screening with low-dose chest CT (LDCT) constitutes an effective tool to allow physicians to detect lung cancer early and plan curative treatment. The National Lung Screen Trial (NLST) published in May 2013 demonstrated at least 20% lung cancer-specific mortality decrease and 6.7 percent all-cause mortality benefit with implementation of yearly LDCT in select populations.
There are currently two accepted criteria for yearly screening LDCT as follows:
NCCN Category I:
1. People ages 55-80 with
2. Thirty pack-year smoking history or greater and
3. Current smoker or quit within the past 15 years
FOCUS REPORT ON LUNG CANCER
COMMISSION ON CANCER STANDARD 4.2 AND 4.6BY DANIEL SAKET MD
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NCCN Category IIA:
1. People ages 50 or greater with
2. 20 pack year history or greater plus
3. One additional risk factor (COPD, pulmonary fibrosis, or occupational exposure).
It has been strongly recommended that lung cancer screening be performed in specialized, high-volume centers that have access to multidisciplinary care, including thoracic radiology, minimally invasive thoracic surgery, interventional pulmonology, medical oncology, radiation oncology, and nurse navigation. In 2018, PIH Health performed 497 screening and follow up exams. Each exam is read by a physician board certified in radiology. All abnormal exams are discussed by a multidisciplinary team for follow-up recommendations.
Staging
About 3 percent of lung cancer screenings result in a cancer diagnosis. Once lung cancer is suspected, the first step is to identify the extent or the stage of the disease. Lung cancer is staged based on the standard TNM classification scheme, which takes into account tumor size/location, lymph node involvement, and distant metastatic disease. Stages I & II are considered early stage lung cancer, and can often be cured by surgical resection. Five-year survival rates are currently greater than 50 percent for stage I, 30 percent for stage II, 5-15 percent for stage III, and less than 1 percent for stage IV. Unfortunately, lung cancer often presents late and only 24 percent of cases are diagnosed in the early stage. Yearly screening with LDCT, however, is driving detection into earlier stages where the disease can be cured.
Treatment
The primary treatment for early stage lung cancer is surgical resection, preferentially with a minimally invasive approach. Intermediate stage cancers can be treated with neoadjuvant chemoradiation followed by resection. With late stage cancers, an attempt to control both the disease and symptoms can be achieved with chemotherapy or biotherapy (alone or with concurrent radiation treatment).
Many lung cancers have a genetic mutation that can be detected by laboratory testing. These tests look for biomarkers on the cancer cell that allow the oncologist to personalize treatment for the patient’s unique needs. In 2018, the Cancer Committee conducted a study that looked at all stage IV non-small cell lung cancer cases diagnosed in 2017. The goal of the study was to measure how many patients had molecular testing in accordance with national guidelines. The study found that 78 percent of patients were tested for one or more biomarker(s) as recommended by national guidelines. Some patients did not require testing as it was not essential for the care they elected to receive.
Every lung cancer patient at PIH Health Hospital- Whittier is assigned a nurse navigator and is discussed in a weekly multidisciplinary tumor board by physicians of all relevant specialties. At this tumor board conference, every patient case is discussed and recommendations are made for further work-up, tests, and treatment. The goals are to implement best practices and expedite delivery of care.
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Conclusion
Lung cancer is a common and deadly disease, which often presents itself late in the disease course. Lung cancer screening with yearly low-dose chest CT (LDCT) is an effective early detection tool and is now shifting the distribution curve toward earlier and curable stages. At PIH Health, we have implemented a robust screening program and established an advanced Multidisciplinary Thoracic Oncology Program, with the aim of serving our community and improving the lives of our patients.
PIH Health had 122 analytic lung cancer cases in 2017.
Figure 1Number of Lung Cancers Diagnosed at PIH Health Hospital - Whittier from 2007-2017 1,075 Analytic Cases
Figure 2Lung Cancer Age Distribution - National Comparison
Table 2
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
80 88 82 78 85 93 94 111 115 127 122
Cas
es
0
28
56
84
112
140
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
8088
82 7885
93 94
111 115
127122
Table 1-3
PIH Health Hospital- Whittier All Cancer Programs in US 4
20-29 0% 0%
30-39 0% 0%
40-49 1% 3%
50-59 5% 16%60-69 22% 32%
70-79 44% 33%
80-89 23% 15%
90-99 5% 1%
Perc
ent
0%
10%
20%
30%
40%
50%
Under 20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
1%
15%
33%32%
16%
3%0%0%0%
5%
23%
44%
22%
5%1%0%0%0%
PIH Health Hospital- WhittierAll Cancer Programs in US
5
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Figure 3Lung Cancer Diagnosed 2017 by Race
Figure 4Lung Cancer Stage Distribution 2013-2017
Table 1-4
Race Percentage
Spanish/Hispanic, NOS 34
White (Non-Hispanic) 69
Mexican 25
Asian 7
South/ Central American 2
Black 2
Filipino 3
Chinese 4
Japanese 1
Japanese1%
Chinese3%
Filipino2%
Black1%
South/ Central American1%
Asian5%
Mexican17%
White (Non-Hispanic)47%
Spanish/Hispanic, NOS23%
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ABSTRACT INFORMATION SEX STAGE
Year Cases Analytic Non-analytic M F 0 I II III IV UNK/ NA
2013 114 98 16 43 71 0 25 4 15 50 4
2014 134 111 23 65 69 1 30 11 15 40 7
2015 131 115 16 69 62 1 31 10 16 53 4
2016 145 127 18 66 79 9 31 14 15 51 7
2017 148 122 26 66 82 7 46 9 12 46 2
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Figure 5Non-Small Cell Lung Cancer 2016 Stage Distribution – National Comparison
PIH Health Hospital- WhittierAll Cancer Programs in US
0 0.08 0
I 0.26 0.32
II 0.12 0.1
III 0.08 0.18
IV 0.41 0.38
UKN 0.05 0.02
80-89 0.23 0.15
90-99 0.05 0.01Pe
rcen
t
0%
10%
20%
30%
40%
50%
0 I II III IV UKN 80-89 90-99
1%
15%
2%
38%
18%
10%
32%
0%
5%
23%
5%
41%
8%
12%
26%
8%
PIH Health Hospital- WhittierAll Cancer Programs in US
7
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The 2018 PIH Health Comprehensive Community Cancer Program Annual Report was prepared by Nathan Honda MD; Sarah Merkle RN MSN AOCNS; and Daniel Patino-Ruiz CTR under the purview of the Cancer Committee.
Thank you, Dr. Daniel Saket, for preparing the special report on Lung Cancer.
For more information about the PIH Health Comprehensive Community Cancer Program, call 562.698.0811 Ext. 12456 or visit PIHHealth.org/CancerCare.
ACKNOWLEDGMENTS
REFERENCES
• Cancer Program Manual, 2016, American College of Surgeons Commission on Cancer, Chicago
• Manual for Staging of Cancer, 8th Edition, American Joint Committee on Cancer, Springer, New York, NY 2016
• Cancer Facts & Figures, 2018, American Cancer Society Inc., New York, New York
• California Facts & Figures, 2018, American Cancer Society, California Division, Inc., Oakland, California
• PIH Health Cancer Registry Statistical Database
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Main Hospital Number 562.698.0811
Breast Oncology Nurse Navigator 562.907.0667 Ext. 15326
Cancer Program Education/Support Groups 562.698.0811 Ext. 12570
Cancer Information Hotline 562.945.8326
Cancer Registry 562.698.0811 Ext. 12896
Clinical Trials Department 526.698.0811 Ext. 12930
Colorectal Oncology Nurse Navigator 562.698.0811 Ext. 12580
Hospice of Presbyterian 562.947.3668
Home Health 562.902.7763
Infusion Services 562.698.0811 Ext. 12641
Lung Cancer Screening Program 562.967.2892
Lung Nurse Navigator 562.698.0811 Ext. 11271
Lymphedema Program 562.698.0811 Ext. 12594
Nutrition Services 562.698.0811 Ext. 11320
Oncology Resource Center 562.698.0811 Ext. 12820
Patricia L. Scheifly Breast Health Center 562.907.0667
PIH Health Hematology/Oncology Clinic 562.789.5480
Radiation Oncology 562.696.5964
Website Address PIHHealth.org
DIRECTORY OF SERVICES
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A = Analytic
Cases that are first diagnosed and/or received all or part of their first course of treatment at PIH Health Hospital - Whittier.
N/A = Non-Analytic
Cases that are first diagnosed and treated elsewhere, then later admitted to PIH Health with disease.
NA
Not Applicable. Some types of cancer do not have staging schemes.
Life Table Method
The life table method involves dividing the total period over which a group is observed into fixed intervals, usually months or years.
Relative Survival
The ratio of the observed survival rate to the expected rate for a group of people in the general population similar to the patient group with respect to race, sex and age. The relative survival rate represents the likelihood that a patient will not die from causes associated specifically with his/her cancer at some specified time after diagnosis
Stage at Diagnosis
The extent of disease based on all diagnostic and therapeutic evidence available by the end of the first course of therapy or within four months after beginning treatment.
TNM Staging System
The TNM system is an expression of the anatomic extent of disease and is based on the assessment of three components:
• T The extent of the primary tumor
• N The absence or presence and extent of regional lymph node metastasis
• M The absence or presence of distant metastasis
TNM Stage Groupings
After the T, N and M has been assigned, they are grouped into stages. The grouping ensures, as far as possible, that each stage group is relatively homogeneous with respect to survival and that the survival rates of these stage groupings for each cancer site are distinct. Carcinoma in situ is categorized Stage 0; for most sites, a case with distant metastasis is categorized Stage IV. Stages I, II, and III indicate relatively greater anatomic extent of cancer within the range from Stage 0 to Stage IV.
Survival Rate
A statistical index that summarizes the probable frequency of specific outcomes for a group of patients at a particular point in time.
UKN
Unknown.
GLOSSARY OF TERMS
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