׉?ׁB!בCט((u׉׉ 7cassandra://7jZHAdG1K-HaqxeRAcITraCRGTR3O-x62rleK8C4VOk`׉ 7cassandra://W4rxdWaCmUYTOLw2puj4FhU8kU4-D2BhEAjAHyf8YSUtX`m׉ 7cassandra://WZiYpBHxYTKn6sd0YAql67bsGpJbmRXsm_P_PN8zyqs+`K׉ 7cassandra://TZxDbJL0y9Ni0qzk73z8hWyMCSE974k-ctQAoDRwqdU ͠^&tXט(u׈׈E^&tX׉EuThe Journey is personal 2019 CANCER PROGRAM ANNUAL REPORT Based on 2018 Outcomes Center for Cancer & Blood Disorders ׉ 7cassandra://WZiYpBHxYTKn6sd0YAql67bsGpJbmRXsm_P_PN8zyqs+`K^&tX^&tX PבCט(u׉׉ 7cassandra://J54-_cUlMAfGy0HShcTcukiQTgpMc-Y2EoVYYKbeVO4`׉ 7cassandra://cI6pPJFbfJEZjVrXAhPHaKI8G04RhKj4VEqhPedEwjg͡j`m׉ 7cassandra://tgFFgXdSyYnVZomBPrrX2hhdqEGYf8fLmLbyQJPHVe8:`K׉ 7cassandra://9NOGq8gZZutaiqDNPk2m8zd5valihVgkMTHJTiWadhQ*3~͠^&tXט((u׉׉ 7cassandra://-Wqa1qMEuINfGXWXDxlKU3zGClKyWF69SSKRocs6kgwRv`׉ 7cassandra://CTZg2XspmJewGpO0HdrSsFmhuVLDT4mZCZ-wEeUZ45Eͳ`m׉ 7cassandra://2oDMHO-d_xL0GltYnYVzI9fFqPhPmWYI10cm3H0aREM?5`K׉ 7cassandra://n7W5nSzpRTepe3WMqwNg5KVKUH4n9Tdr9y3hOqFRMAQ̂͠^&tX׉E'The Journey is personal Relay for life ׉ 7cassandra://tgFFgXdSyYnVZomBPrrX2hhdqEGYf8fLmLbyQJPHVe8:`K^&tX׉ETABLE OF CONTENTS A Message from Leadership 2 Tumor Board and Cancer Committee The Journey is Personal: Three Patients Navigate Different Paths – Carol’s Journey, Teresa’s Journey, Charles’ Journey Analytic Cancer Case Distribution Clinical Case Study – Primary Site: Anal Carcinoma The Journey is Personal: Claire’s Journey with Hereditary Cancer Annual Cancer Symposium Community Outreach 3 4 8 8 10 12 13 ׉ 7cassandra://2oDMHO-d_xL0GltYnYVzI9fFqPhPmWYI10cm3H0aREM?5`K^&tX^&tX PבCט(u׉׉ 7cassandra://ivcCC-lK23dBXyB2XzQGefzRXTXj5fmfAWMvZ4RaGIM`׉ 7cassandra://6v3YPipCEs0jlu3jTWJI9gzXLp4tR0hY51exdBTeLAI`m׉ 7cassandra://SwHG9PbqbDMoyM-8jmqsFAG51aHs0zFxmaBwtiBAul48`K׉ 7cassandra://JXac7ZAZAhnJuuEXCk3-IztZBQZ27wAlNmZvERt9yz8͠^&tXט((u׉׉ 7cassandra://VREKLR0mFREDNfESMpGAwDkZzrFImcJQgxcW3RgWyRQ`׉ 7cassandra://S8bPmrnNAvAcsGi4xVI8Wp9LwF8xhi_K2jX1TiFuJ4A=`m׉ 7cassandra://93YPC0_-cArOLZN35MPHqV5UmR1DUmlJyUfvtmQ6TUME`K׉ 7cassandra://Fn-Gx_c_6MOTI-tzz2p06b3tuw2vxFW6qc10cGUCu-A)0͠^&tX׉E A Message Kelvin Raybon, MD, FACP In September 2017, I came to Augusta Health to be the Medical Director for the Cancer Program and Infusion Services. In January of this year, I was asked to be the Chair of the Cancer Committee, a position that was previously held by Drs. Ron Turnicky and Rob Kyler. I owe both of these men a tremendous gratitude for their leadership and engagement at Augusta Health. Their leadership allowed tremendous growth and success of both the medical and radiation oncology programs, and were instrumental in integrating cancer care with radiology, pathology, surgery, and other medical fields in our health system. Tremendous advances have been made in recent years in understanding the biology of cancer, and this knowledge is rapidly leading to better but more complex oncologic care. Medical treatments may utilize very specific drugs targeting a single mutation, or nonspecific treatments that stimulate our immune system to recognize and fight cancer. Hormonal and chemotherapeutic drugs remain important weapons, and using combinations of these approaches increasingly shows promise in producing better outcomes. With new more complex therapies come the potential for new and unusual side effects and toxicities, increasing the importance of on-going attention to individualized symptom management and coordination of care in the clinic. We are therefore fortunate to have added a third nurse navigator to help our patients manage their way through active treatment. Along with us providers and the members of the Cancer Committee, the leadership at Augusta Health understands how important it is for each and every patient to have the resources of a navigator, an advocate for the patients and their family members, and someone to help them manage the day to day challenges to getting the care they need. While our focus at the Center is often on taking care of patients who were recently diagnosed with cancer, or who are managing their cancer as a chronic disease, our Cancer Risk Assessment Program or “Genetics Program,” continues to grow by leaps and bounds. The medical field has only now begun to reap the benefits from our knowledge of human genes, how they function, how they become dysfunctional in malignancies, and how we may be predisposed to various degrees to all human illness, especially cancer. We believe our program to be one of the best community cancer genetic programs available, and it daily helps patients understand how to manage or reduce their risk of developing cancer. This year, we were able to pilot an electronic genetic screening program in Fishersville Primary Care and Dr. Flather’s Gynecology Office. During routine visits patients were offered the opportunity to answer a series of questions about their personal and family history of cancer. Based on those answers, the software program can indicate whether or not the patient would benefit from further genetic questioning, counseling and, perhaps, testing. Nearly half of all patients screened are referred for some additional questioning and counseling, and for those for whom testing is recommended and positive, a strategic plan is developed to reduce risk and detect any future problems at the earliest, most curable time. Expanding genetic screening to other practices is certainly planned. Oncology remains a challenging field, but advances in diagnosis and management will continue, and we remain committed to utilizing these advances to reduce the impact of cancer on the people of the Shenandoah Valley. From Leadership 2 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 ׉ 7cassandra://SwHG9PbqbDMoyM-8jmqsFAG51aHs0zFxmaBwtiBAul48`K^&tX׉E2019 CANCER COMMITTEE MEMBERS 2018 TUMOR BOARD Patient-focused weekly Tumor Board meetings provide a forum for discussion of complex cases. Multidisciplinary physician attendance and presentation of National Comprehensive Cancer Network guidelines contribute toward the most appropriate management of the disease. Clinical trial options are also discussed as presented by physicians and the Research Coordinator. The Augusta Health Tumor Board is also supported by Duke Health physicians who attend via video conference. Cases presented in 2018: 234 Annual Analytical Caseload 2018: 31.49% (234/743) Cases presented prospectively: 94% (220/234) Average of physician attendance: 12 Average of non-physician attendance: 10 Robert Kyler, MD, Radiation Oncologist, Cancer Conference Coordinator Naheed Velji, MD, Medical Oncologist and Center Liason Physician (CLP) Kelvin Raybon, MD, Medical Oncologist, Program Director Matthew Shapiro, MD, Diagnostic Radiologist William Thompson, MD, Surgeon John Girard, Administrative Director Cancer Services, Cancer Program Administrator Renee Muellenbach, MSN, RN, Oncology Nursing Leigh Anderson, LCSW, Social Worker and Psychosocial Services Coordinator Iva Jackson, CTR, Certified Tumor Registrar Pat Benson, MSN, RN, CMSRN, CPHQ, Quality Improvement Coordinator Cindy Allen, MD, Pathology, Cancer Registry Quality Coordinator Amanda Wilson, NP, Palliative Care Professional Catherine Raines, CHES, Community Outreach Coordinator Lisa Lenker, BS, CCRC, Clinical Research Coordinator Donna Markey, MSN, RN, ACNP-CS, Oncology Nurse Practitioner, Genetics Prof. Additional/Other Members William Jones, MD, Urology Carmen Gonzalez, MD, Pulmonology Jared Davis, MD, Pain Management Joe Surratt, AGACNP-BC, Gastroenterology Mary Beth Landes, MS, RD, CSO, Registered Dietician Clay Wilson, PharmD, BCOP, Pharmacist Stephanie Mims, PT, DPT, MBA, Director Therapies, Rehabilitation Services Rev. Rob Adrian, Pastoral Care Representative Annika Dean, American Cancer Society Representative Rader Dod, RT (R), Director, Radiology Donna Berdeaux, RN, Breast Navigator Megan Howell, BSN, AE Navigator Colleen White, RT (R) (T), Chief Radiation Therapist Mary-Kate DePriest, MSN, RN, Director of Clinical Operations 3 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 ׉ 7cassandra://93YPC0_-cArOLZN35MPHqV5UmR1DUmlJyUfvtmQ6TUME`K^&tX^&tX PבCט(u׉׉ 7cassandra://ot9mAPA8pG3yawiqhkEeSCSyhCwmCX_dVokQRtAThfM`׉ 7cassandra://EhCyiZZ5Dywa_FG0tOa3C0_DuQ-v339wdryE_xOdJRc`m׉ 7cassandra://vV6vrkgEg_vDzn2x0Ft2tt53_QP4bcIndhT1yi9ll6w=`K׉ 7cassandra://mF5YgJ4-gaJGuj9NKBhhbzbpvSXKBoOTpgZpblntvDUm͠^&tXט((u׉׉ 7cassandra://h5yvwXsCR3ujuNeOak2cwPoKBI1UILheRoYwNBmcZQg `׉ 7cassandra://4s8AvpELfFMYxshW7JnZSRK3kosOFX2mABGp-k4AVhkC`m׉ 7cassandra://xD2RtI112OJgs7f9wGAif6lNVxbKAb59Az0tRBJpvkE7`K׉ 7cassandra://Pi9UXb5ROiOKCEvPXwO7zD0epbf_DjUWox0osSPsjfQͿ͠^&tX׉E The Journey There is no typical breast cancer patient. There is no typical lung cancer patient. There is no typical prostate cancer patient. There is no standard protocol for treating cancer. That’s because each cancer is unique and each cancer patient is an individual navigating what has come their way. Like all of us, they are each on a journey. And for each of them, the journey is personal. Donna Berdeaux and Carol Cobb is personal CAROL’S JOURNEY Carol Cobb was diagnosed with cancer after she found a lump in her armpit during her monthly self-exam. It was almost exactly on her 70th birthday. “My first honest thought was, ‘Well Happy Birthday to me,”’ she says. “But then, I decided to react positively. I like to be completely informed, both the good and the bad. I like to have all the information possible so I can deal with it and make decisions.” So she began looking for resources and headed to the Augusta Health website. The first thing that popped up was a photo of breast cancer navigator Donna Berdeaux, BSN. So Carol picked up her phone and called her. Donna answered, and said, “I was literally just picking up the phone to call you.” Turns out, says Carol, they were a perfect match for each other. “I’ve learned, as I’ve gone through the phases of my treatment, Donna is my VIP,” says Carol. “I can email her or call her whenever I need. She is so completely informed on everything: side effects, bruising, scars and what to expect next. Reassuring me that what I’m experiencing is normal. She has a knack for providing the perfect amount of attention—not smothering, but just the perfect amount of help. My husband admires her, too. She goes out of her way to be sure 4 continued on page 5 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 Breast Cancer Navigator Donna Berdeaux, BSN, guides breast cancer patients through their journeys at Augusta Health’s Center for Cancer and Blood Disorders. “A cancer diagnosis is scary, and patients are understandably nervous,” says Donna. “So are their families. Everyone reacts a bit differently,but they are all facing the unknown and all looking for information. So one of my key roles is to alleviate the initial anxiety, and often that’s done by providing accurate information. Looking on the internet about a cancer diagnosis can be terrifying. There’s a large amount of information on the web, and trying to find the right information can be overwhelming. I can become their resource.” “Everyone has different needs and everyone will have different treatments, depending on their pathology. They also have experiences and emotions that are unique,” she explains. “My patients aren’t their disease; they aren’t ‘Carol, who has breast cancer.’ She’s Carol, who loves knowledge and teaching, who is a very involved grandmother and who, just like me, likes rocks and geology. She is a whole person, and that’s how I treat her.” ׉ 7cassandra://vV6vrkgEg_vDzn2x0Ft2tt53_QP4bcIndhT1yi9ll6w=`K^&tX׉Ehe’s comfortable with all that’s happening, too. I can’t imagine how others go through the cancer experience without a navigator like Donna.” Carol wants to move as quickly as possible through her treatments, so sometimes schedules many appointments on the same day. She appreciates the responsiveness of all her providers and the scheduling staff. She’s had a port implanted, and began infusion. Her infusion “recipe” was a bit strong for someone of her age, but she chose to do all treatments in a row. “Dr. (Kelvin) Raybon, my oncologist, has also been wonderful,” Carol adds. “He explains everything and has answered all my questions, even those I didn’t know to ask. He teased me about doing a ‘young lady’s dose’ of chemo, but said I would see great results. And I did. When I had my lumpectomy, they found nothing—the breast tumor was gone and all lymph nodes back to normal size. That’s important. Just a few years ago, my type of cancer would have been really dismal news, but Herceptin and Monoclonal Antibodies have changed everything about survival rate.” So has her positive attitude. Carol explains, “Two weeks before I started treatment, I went to the Breast Cancer Support Group meeting at Augusta Health. As I sat in that meeting and looked around the room at all those beautiful ladies, all doing well, I realized, “I can do this. If they can do this, I can do this.” The Support Group members, especially those who have finished treatment, have become her ‘mentors’. They are another source of information and encouragement, especially with tips about dealing with symptoms and side effects such as fatigue. The Support Group has also become an active social network. Their activities include planning a fund-raising Tea to support breast cancer in a way voted on by the group, field trips to places like the lab to see how pathologists diagnose cancer and even longer “fun” trips. Next up, they’re headed to Williamsburg. Carol is still in active treatment. She finished six infusions, and was quite excited to ‘ring the bell’ as she passed the milestone. Her friends and family attended, and the nurses and staff staged a special parade complete with gold pompoms. Next, she begins six weeks of radiation treatments. As she faces the next phase of treatment, she remains positive. “I can do this,” Carol says. “I know I can do this.” Megan Howell, RN, BSN, is Teresa Layne’s nurse navigator. “I love my role as an oncology nurse navigator,” say Megan. “I get to work with patients during a difficult time in their lives. Hearing the words you have cancer is extremely scary and I am present to be their support and advocate. Cancer does not discriminate; I get to meet patients from all walks of life with different backgrounds. My goal is to get to know each of my patients so I can help make their diagnosis and treatment transitions as smooth as possible.” “I have worked with Teresa over the last few years. She is such a wonderful inspiration to me and to everyone who has the pleasure of being in her presence,” adds Megan. “Teresa has taken a diagnosis of stage IV lung cancer in stride and continues to smile and maintain a positive attitude. I enjoy conversations with Teresa about vacations, Halloween costumes, and her wild cat. She is more to me than just a patient. Teresa knows the importance of lung cancer screening and awareness and promotes this to help others. I feel blessed to be Teresa’s nurse navigator and feel that we learn so much from one another.” 5 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 Megan Howell, Teresa Layne and Amanda Layne TERESA’S JOURNEY In a way, Teresa’s journey began on another path. After a series of urinary tract infections, her physician decided to have a CT scan of the bladder to see if he could determine a cause. The CT of the bladder incidentally included part of her lung. In her lung, there was a mass. “I was in a bit of a daze,” Teresa says. “My mother had continued on page 6 ׉ 7cassandra://xD2RtI112OJgs7f9wGAif6lNVxbKAb59Az0tRBJpvkE7`K^&tX^&tX PבCט(u׉׉ 7cassandra://6a8ZHj_DtCUHcSIp9Gn5VHNG6azM1n6hFDmPsEDo24c`׉ 7cassandra://TvkSmjgSXjufmu6v7yEE6ssp17vIgBZQxHuAiYwG4S4`m׉ 7cassandra://nXJ4nm18Fnphqt8Zy6ZGY-HgEPCNp3y0UR_yK2v_hfA;`K׉ 7cassandra://AA4T3hpffrdX3Jv7Ecm1HnM693KNzwJ7ntTyd4x29lw͠^&tXט((u׉׉ 7cassandra://OG3lN6p2eJkLCugnmASnXD8YKg6eZQgVLu7gSChkHB8 `׉ 7cassandra://iBXc06CNSpU5J7fRX3udUB1WV-4GbMjEQrvVvEMWAuY`m׉ 7cassandra://pCzT08S2DOrZRhKG7J5H6MyugEphGn4CSrvL5WJciMo74`K׉ 7cassandra://Jius4WBB4IF_DvNShShRmRtYWPooq3BERxtGVMMEues= ͠^&tX׉E+just passed away the week before, and the last thing you expect from a visit to the urologist is to learn you might have lung cancer. And it was about 5 pm on a Friday afternoon.” She had a long weekend ahead of her. But within two hours, on Friday evening, she’d been contacted by thoracic surgery. She was in the office on Monday morning. A navigational bronchoscopy quickly confirmed she did have cancer, and she was referred to an oncologist. “My oncologist was Dr. Judson, who had been my mother’s oncologist,” Teresa explains. “When he walked into the appointment, I think he was surprised to see me as a patient.” Her journey began in 2016. Since then, she’s had several types of chemotherapy, some more productive and some better tolerated. A diagnosis of Stage IV lung cancer is difficult, but she keeps moving forward and taking whatever steps needed to keep moving forward. One constant throughout her treatments has been her daughter, Amanda, who has worked in Information Technology at Augusta Health and has been with her mother at most of her treatments. many good websites for information. She’s been to every chemo treatment, even if it’s just been to pop in and say, ‘Hey, how are you?’” Teresa’s also kept a positive attitude throughout her treatment, and she believes she’s been able to do that because of her rapport with the nurses. They all encourage each other with appropriate humor, which is possibly best illustrated by “the hats”. When Teresa began losing her hair, a dear friend crocheted some hats for her. Not just any hats, but silly hats—one that looked like Helga the Viking and one that looked like she was wearing pink sponge curlers. At that point, the hats became the thing. Each chemo session was a different hat. Friends gave her funny hats. She and her family would search for hats. “If we found something outrageous, we just had to buy it,” says Amanda. “We had pilot goggles, mouse ears, one for every holiday.” The collection grew to almost 50 hats. In fact, she actually helped build the computer system modules used in the Cancer Center. “I have a personal investment in the system,” says Amanda. “I also have tremendous support from my husband, children, grandchildren and so many other friends and family,” adds Teresa, “and my faith keeps me encouraged. It keeps me centered on what is truly important.” In addition to having Amanda at her treatments, her ‘other family’—the Cancer Center staff, especially the nurses—have been with her, too. Her navigator, Megan Howell, has become her single point of contact. 6 “Megan’s awesome,” says Teresa. “I think the best word to describe her is that she’s an expediter. If I’m having trouble connecting somewhere, she can do that for me and get me where I need to go. She’s referred me to She also dressed for each Halloween. Last year, she went as Uncle Fester from the Addams’ Family, complete with a lightbulb that lit when she put it in her mouth. “It’s important to keep your spirits up, and the nurses really help me do that,” says Teresa. Teresa’s on a ‘chemo break’ for a while to get some dental work done. She’s had another scan and her new oncologist, Dr. Naheed Velji, says things are working, so…so far, so good. What’s next in the journey? “I’m going to Disney World,” says Teresa. And Amanda confirms that plans are in the works AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 for the entire family to make the trip in 2021. “I don’t ask about end times,” adds Teresa. “As long as I’m living well and feeling well, I’m good.” CHARLES’ JOURNEY Charles Meeks, a retired middle school language teacher from Covington, has always been a pretty healthy guy. So he was surprised in February, when test results from a regular visit to his primary care physician in Bath County showed an elevated PSA. Because his PSA has always been normal, and his prostate looked normal, his physician prescribed an antibiotic first, to take care of any possible infection. About a month later, he saw urologist Dr. Sam Graham and the PSA was even higher. Dr. Graham changed the antibiotic, but because the PSA was still elevated, ordered an MRI. The MRI did reveal a spot, so Dr. Graham performed a biopsy. The biopsy confirmed cancer. continued on page 7 Charles Meeks and Angie Shy ׉ 7cassandra://nXJ4nm18Fnphqt8Zy6ZGY-HgEPCNp3y0UR_yK2v_hfA;`K^&tX׉EThe Journey is personal “I was a bit shaken,” says Charles. “You never think cancer will happen to you. Dr. Graham also explained that my Gleason score was on the high end, above 9, which means an aggressive cancer. Before I left the office, Dr. Graham was on the phone with Dr. (Robert) Kyler to set up an appointment.” Dr. Kyler is a radiation oncologist in the Augusta Health Center for Cancer and Blood Disorders. Charles was understandably anxious about his diagnosis. “My first appointment with Dr. Kyler was a week later,” he explains. “I really couldn’t eat or sleep, and I was losing weight. Then, while checking in for my appointment, Angie came up and introduced herself to me.” Angie Shy, RN, is Charles’ navigator. “Angie gave me a good feeling right away. She was positive and encouraging, and she gave me the impression that we were going to lick this thing,” says Charles. “She went with me to my appointment with Dr. Kyler and took very detailed notes. And thank goodness she was there. I couldn’t remember much of what Dr. Kyler said, but her notes laid everything out clearly.” He left the appointment feeling encouraged. A bone scan was ordered to be sure the cancer was contained within the prostate. Angie helped make arrangements for the scan and even showed up to be support during the imaging procedure. Since Dr. Graham had retired, Charles was now a patient of urologist Dr. Brian Stisser. Angie would also accompany him to those appointments to take notes. “No matter how long the process or appointment, and some were two hours long, she was always there. She was always upbeat and she was always positive,” says Charles. “I can tell Angie really loves what she does, and that she really does care about me.” Charles began radiation treatments on September 9. He was initially scheduled for 40 treatments, but after the second week, the number of treatments was reduced to 28 because more intense, exact radiation could be used. He appreciated that because the journey from Covington to Fishersville for treatments is 80 miles one-way, a four hour drive for a 15 minute radiation treatment. The last radiation treatment was October 16. “I really haven’t been to too many hospitals,” says Charles, “But I don’t see how the care could be better anywhere else.” After a two month wait, as the year comes to an end, Charles will repeat his blood work. If his PSA is below 1, he will have licked this thing. AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 Angie Shy, RN, is Charles’ navigator. “It takes time for many of us to understand and process new information, and the word cancer can cause someone to completely shut down,” says Angie. “Having a navigator in the room during appointments can be really vital for a lot of people experiencing a new cancer diagnosis because we as navigators already have a foundation of knowledge about the cancer diagnosis and treatment. We also take notes and are available through a phone call or email with any other questions or clarifications that come up. It is important as a navigator to understand how our patients are feeling and how they are processing. Navigators can be a single point person for the patient and the other staff members involved in their treatment.” Angie explains, “I like to enter the room before meeting a new patient a few minutes before the doctor and get to know the person I am meeting a little more. This helps me to understand their personal background and empower them to ask questions that are pertinent to their lifestyle. Every experience is different for cancer patients. I enjoy personalizing the patient’s experience so that they don’t completely dread the process and give them the confidence to see the journey through.” 7 ׉ 7cassandra://pCzT08S2DOrZRhKG7J5H6MyugEphGn4CSrvL5WJciMo74`K^&tX^&tX PבCט(u׉׉ 7cassandra://BHY4g6UP-iqbxNbOOw8haAjL0goaqItXqtWTd_hlJhI`׉ 7cassandra://MpcnVSOptWRxK_sXnABmhnww0hvlsnuJzFUmg30B010`m׉ 7cassandra://UZ352YMULxR8YaWAFN21SrsZGWcsi1K0PydZw_0AAwI<`K׉ 7cassandra://VEqya4jiGo_txROM09vYFSvt2sxQ0DbHrxKlS07MXsc̄͠^&tXט((u׉׉ 7cassandra://tyrxve0yvBAMdXOLtcXls3ifMD_sGc1eN29rxM1XikA*`׉ 7cassandra://Klad_2EIZeVKwDRIiUBXo-nLJCfw-uIfIK823-6_mIA͛`m׉ 7cassandra://dJijdAB0uUKs95XOC8J7JM_Ewm47rBamARjZH6uFgQU*`K׉ 7cassandra://BKBJ_TxtdwCLiVPJVWh_R2wT4DEt675Cns6013ZQZFQ^͠^&tX׉E 2019 Standard 4.6 Monitoring Compliance with Evidence-Based Guidelines Prepared by: Kelvin Raybon, MD, FACP, Medical Director, Center for Cancer & Blood Disorders important features. Along with cervical and oropharyngeal carcinomas, it is one of the malignancies associated with infection with the Human Papilloma Virus (HPV), and is expected be amenable to eradiation by means of vaccination of young unexposed people to HPV. Another important feature is its curability; anal carcinomas can be successfully cured in a majority of patients by a combination of radiation and cytotoxic chemotherapy, making appropriate evaluation and therapy imperative. Introduction Anal carcinoma is an uncommon disease. In 2019 there will be an estimated 8300 new cases in the United States, with an estimated 1280 deaths (American Cancer Society website, October 2019). Despite its relative rarity, it has several 2018 Analytic Cancer Case Distribution (N=727) MALE GENITAL 12% RESPIRATORY SYSTEM 18% Anal carcinomas are squamous cell cancers, and typically present with pain or bleeding with defecation; they are often initially mistaken for hemorrhoids. Risk factors for anal cancer include genital warts, increased number of sexual partners, infection with HIV, and smoking. Incidence is twice as common in women than men. Diagnosis is made by examination and biopsy; staging includes imaging with CT scans, supplemented with MRI or PET/CT if needed. Prognosis depends on clinical staging, and worsens with local nodal spread and increasing size of tumor. DIGESTIVE SYSTEM 20% Treatment historically was surgical, with the morbidity of a permanent colostomy and an overall cure rate of about 50%. However, neoadjuvant treatments with radiation and chemotherapy during the 1980’s led to the realization that anal cancer can be cured with radiation and chemotherapy only, reserving surgery only for salvage (J Natl Cancer Inst 1989; 81:850-56). Attempts to improve on a combination of mitomycin and 5-flourouracil given with radiation (Cancer 1983; 51:1826-29) have largely been unsuccessful (J Clin Oncol 2012; 30:4344-51), and this combination remains standard of care (Curr Opin Oncol 2007; 19:396-400). The expected cure rate with combined modality therapy is 70-80%, with an overall 5 year survival of greater than 65%. BREAST 20% BLOOD & BONE MARROW 6% Monitoring Compliance with Evidence-Based Guidelines BRAIN 3% Other/Ill-defined 0% ORAL CAVITY 1% SKIN 1% ENDOCRINE 1% CONNECTIVE/SOFT TISSUE 1% 8 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 FEMALE GENITAL 2% UNK PRIMARY 1% LYMPHATIC SYSTEM 3% URINARY BLADDER 11% Current standard of care guideline used for this review is National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2019, most recently updated 04/25/2019. Methods All cases of anal cancer diagnosed at Augusta Health in 2018 were identified through tumor registry and chart review. Data was individually extracted and reviewed for compliance with standards per NCCN guidelines as noted. continued on page 9 ׉ 7cassandra://UZ352YMULxR8YaWAFN21SrsZGWcsi1K0PydZw_0AAwI<`K^&tX׉E