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Cancer CenterA National Cancer Institute

Community Cancer Centers Program

2013AnnualReport

www.billingsclinic.com/cancer

ii

Table of Contents

» Directors’ Report 1

» American College of Surgeons Accreditation 2

» Unique Programs to Billings Clinic Cancer Center 2

• Specialty Radiation Therapy 2• Research Program 3• Specialty Support Programs 4• Outreach Programs 5• Arts-in-Medicine 5• Inpatient Cancer Care: The Journey to Inpatient

Pediatric Oncology Care 6

» New Programs at Billings Clinic 7

• National Accreditation Program for Breast Cancers 7• Reger Family Center for Breast Health 7• iPad Donation Helps Patients Stay Connected 7

» Welcome New Physicians 8

» 2013 Patient Care Evaluation Study 9

» Cancer Registry Milestones 15

• 2012 Primary Site Table 16• Cancer Registry 19

» Awards, Presentations, Publications and Recognitions 24

2013 Cancer Center Annual Report

1

Director’s Report - 2013

Randall Gibb, MD Medical Director

Jo Duszkiewicz Administrative Director

At the end of every year we reflect on the accomplishments of that year with pride. Why, because the focus of our programs are on the patients

receiving best practice medicine and care. The best quality, patient safety, service and value are not only words in our vision, they are core to the physicians’ and staff ’s guiding principles. As we reflect, we put pen to paper to write this annual report, not only for us to share the information with everyone, but to archive the successes and the challenges of the year.

So, we welcome you to the 2013 Billings Clinic Cancer Center’s Annual Report. The contents of this document not only outline the Cancer Center’s meaningful achievements, but also report our cancer statistics for the past year and a quality study reviewing our patients’ care and/or experience at the center.

In addition to the programs you will read in the pages that follow, we also want to share the other unique features of our cancer program:

• NCI Community Cancer Centers Program (NCCCP) since 2007: a program that focuses on improving cancer care in underserved populations, increasing access to cancer clinical trials and improving cancer care delivery across the continuum of care

• Stem Cell Transplant Program (SCT): only accredited (American Association of Blood Banks) SCT program in Montana and Wyoming

• Cancer Care Delivery Research (CCDR): through many community partnerships, active research has been a focus throughout the year

• Pediatric Oncology, Gynecologic Oncology, Naturopathic Medicine and Genetic counseling are clinical programs that are uniquely integrated into our extensive cancer care services

• Multidisciplinary Cancer Clinics: six cancer site-specific clinics are coordinated by patient care navigators and offer cancer patients access to multiple cancer and other specialists in a timely manner

• Advisory Board of Cancer Survivors: a group of cancer survivors meets regularly to discuss opportunities for cancer programs and advise the cancer leadership on ways to improve our services offered

• Outpatient palliative/symptom management program and clinic: a team of palliative care experts meets with patients to assist in symptom management and quality of life issues

We hope you enjoy and find value in this report. In addition to reviewing this 2013 annual report, we encourage you to visit our Billings Clinic Cancer Center website to familiarize yourself with all of our cancer related programs and services.

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The American College of Surgeons (ACoS) Commission on Cancer (CoC) is a consortium of professional organizations focused on improving cancer outcomes through quality, multidisciplinary, and comprehensive cancer care delivery. There are different Cancer Program categories based on type of organization, services provided, and number of new cancer cases diagnosed and/or treated annually at a facility. Billings Clinic is considered a Comprehensive Community Cancer Program, the highest non-academic community hospital category.

Programs accredited by the ACoS CoC undergo a rigorous reaccreditation survey every three years. This involves an assessment of the program’s compliance with the requirements for all standards, completion of an online Survey Application Readiness (SAR) tool with supporting documentation, and an onsite visit by an ACoS CoC surveyor to review program performance.

This year, Billings Clinic underwent its third successful survey and received three-year accreditation with commendation at the silver level. Commendation, which reflects performance beyond the basic CoC standards, was received for six out of the eight standards including: clinical trial accrual, Cancer Registry education, annual report, compliance with pathology reporting according to College of American Pathologist (CAP) guidelines, oncology nurse certification, and registry abstraction timeliness.

At the conclusion of the onsite visit, the surveyor stated Billings Clinic was among the top three programs nationally that he has had the pleasure of surveying. This comment helps validate the continual pursuit of providing excellent cancer care by our many multidisciplinary teams!

malformations in the brain. Gamma Knife delivers very high doses of ionizing radiation to select, well-circumscribed targets in the brain. It is used to treat vascular disorders, benign tumors, metastases and other malignant tumors, and functional disorders such as epilepsy and Parkinson’s disease.

The Gamma Knife Perfexion® unit will be the first in Montana, as well as the four state region that includes Wyoming, North Dakota, South Dakota, and Idaho. Clinical treatment with the Gamma Knife is anticipated to begin in March 2014.

American College of Surgeons Accreditation

Unique Programs to Billings ClinicSpecialty Radiation TherapyBillings Clinic is proud to announce the expansion of radiosurgical services in the region with a new approach to treating brain tumors using the Gamma Knife Perfexion®. Our physicians have completed training with the most renowned Neurosurgeons and Radiation Oncologists from the University of Pittsburgh and Cleveland Clinic to expand their expertise in the field of stereotactic radiosurgery.

Gamma Knife is used for the precise determination and targeting of various intracranial abnormalities, as well as for diagnostic and therapeutic procedures. This technology, with its dose-planning system, Gamma Plan, is a unique device used to non-invasively treat brain tumors and vascular

3

The Total Cancer Care® Program was initiated earlier this year at Billings Clinic. This collaborative program with Moffitt Cancer Center in Tampa, Florida helps us learn more about the specific molecular biology of cancer as it relates to treatment effectiveness. It involves sending tissue from patients diagnosed with lung cancer, breast cancer, colorectal cancer, and melanoma to Moffitt’s biorepository where they not only use the tissue to study the cancer, but also help identify patients for potential clinical trials based on the specific cancer characteristics.

Changes have occurred at the national level with the reorganization of cooperative groups into the National Clinical Trial Network (NCTN). The NCTN will now be comprised of 4 adult groups: Southwestern Oncology Group (SWOG), Alliance (formerly NCCTG, CALGB, and ACSOG), NRG (formerly NSABP, RTOG and GOG), and ACRIN (ACRIN and ECOG). The Children’s Oncology Group (COG) will remain separate. Furthermore, the Community Cancer Oncology Program (CCOP) and National Cancer Institute Community Cancer Centers Program (NCCCP) programs are merging into the National Community Oncology Research Program (NCORP). We are collaborating with MCC and other oncology providers within the region on the writing of a proposal for funding. While NCORP will continue to place a strong emphasis on clinical trial accrual, Cancer Care Delivery Research (CCDR) is a new program component which will focus on oncology care delivery models, cost, quality, and outcomes. Billings Clinic will take an active leadership role in both components of the new program.

Research ProgramBillings Clinic continues to demonstrate a strong commitment to the use of clinical trials in cancer treatment. In 2013, Billings Clinic enrolled 102 cancer patients (7% of analytic cases) on clinical trials.

Collaborative involvement in several community awareness programs continues to help promote awareness of cancer clinical trials. In February, we celebrated Cancer Clinical Trial awareness month with the Montana Cancer Consortium (MCC) and Montana Cancer Control Coalition (MTCCC). Articles were written in newspapers across the state, educational programs were broadcast on community television, and messages were distributed using social media. Later in May, Billings Clinic celebrated International Research Week with the Research Center, Center for Translational Research, Nursing Research committee, and Cancer Research department setting up posters with findings from locally conducted research. Additionally, a lunch and learn program was held to educate staff and the community at large about the research opportunities at Billings Clinic.

Unique Programs (Cont’d)

Billings Clinic Cancer Center Research Associate Susan Carter, meets with a patient to discuss clinical trial options.

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Specialty Support ProgramsA dedicated team of oncology professionals has progressively developed an extensive array of specialty support programs to address patients’ and families’ holistic needs over the past ten years. This team includes ten patient navigators, three licensed social workers/professional counselors, two oncology dietitians, three certified lymphedema specialists/physical therapists, a speech therapist, a genetic counselor, a symptom management nurse, and a lay navigator. Through their expertise, patients’ and families’ physical, psychosocial, and spiritual needs are addressed in a comprehensive and inclusive manner through specialty consultations, as well as group activities such as lunch and learn programs, support groups, annual retreats targeted to specific patient populations, and survivorship education. Additionally, a Facebook group (Billings Clinic Cancer Pathways) was created this fall as a mechanism to utilize social media to further promote awareness among our patients of these wonderful programs and services. Please consider joining this group by going to www.facebook.com/groups/billingscliniccancerpathways

Survivorship support is one area Billings Clinic has been working diligently on over the past year to better integrate electronic medical record (EMR) tools and nurse navigation processes for improved efficiencies in providing cancer patients with survivorship documents. Initial provision of survivorship documents (a comprehensive treatment summary and survivorship care plan) began in 2010 when Billings Clinic launched a 2-year pilot study supported through the National Cancer Institute’s Community Cancer Centers Program (NCCCP). While high levels of satisfaction with the survivorship documents were noted among patients, caregivers, and primary care providers, the time required to complete the survivorship documents (average three hours) was prohibitive.

Lean Six Sigma tools SIPOC (suppliers, input, process, output, customers) diagram, process map, waste walk, fishbone diagram, cause and effect prioritization matrix were applied to survivorship processes to improve efficiency. Institute of Medicine specifications influenced survivorship document design while National Comprehensive Cancer Network guidelines established surveillance plans. EMR forms captured discrete data elements tracked by navigators as patients progressed through the continuum, thereby creating a data repository which could later populate the treatment summary. Standard order sets for surveillance and site-specific survivorship care plans outlining late- and long-term effects of treatment, follow-up care, wellness strategies, and resources were created in the EMR. Four months post-implementation, we are pleased to report these system enhancements have yielded a much improved average of 45-60 minutes to compile the treatment summary and survivorship care plan. Through collaborative process improvement, roadblocks to providing survivorship documents were reduced, thereby improving the quality of care provided to cancer survivors.

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Outreach ProgramsBillings Clinic is committed to collaborating with local healthcare facilities to provide quality oncology specialty services throughout our vast geographic region.

Medical Oncology: Outreach services are provided in eight different sites throughout the region by our expert team of medical oncologists/hematologists. The frequency of visits to each community is dependent upon volume demands. This year a new outreach clinic was started in Worland, Wyoming, which is staffed by Dr. Robert Joseph from our Cody Oncology hub.

Gynecologic Oncology: In addition to gynecology oncology surgical and clinical services provided in Missoula and Helena, clinical outreach was resumed in Bozeman this fall.

Cody Oncology and Infusion Center: The Billings Clinic Cody Oncology and Infusion Center has been in full operation since November 2012, providing full-time medical oncology and infusion coverage to the north-central Wyoming region. Since Dr. Robert Joseph’s arrival in March of 2013, this service has experienced a 53% increase in volume.

The Cody Oncology team works closely with the Billings Oncology team to provide comprehensive services both locally, as well as via telemedicine. Additionally, this team actively participates in multi-disciplinary tumor boards and weekly rounds, enrolls patients to clinical trials, and provides supportive services for patients.

The Cody Infusion Center is staffed five days a week with an RN skilled in providing a variety of treatments, including chemotherapy and a multitude of infusions for other diagnoses. As an increasing array of infusion referrals are received, infusion services continue to expand so that patients living in the north-central Wyoming region can receive treatments closer to home.

Arts-in-Medicine The arts have proven to reduce anxiety, depression, and other difficult emotions that often accompany a cancer diagnosis. Billings Clinic Cancer Center’s healing arts program was bolstered by the LIVESTRONG Foundation’s Community Impact Project grant to replicate the Creative Centers Artist-in-Residence program. This $15,000 grant funded two local artists and all art supplies needed for the program.

The artists, Mur Quaglia and Brooke Atherton, worked at the bedside and chair-side creating art with patients. They created snowflakes, fabric art, paintings, necklaces, a collaborative staff painting, and several other projects. They empowered patients and families with the creative process during treatment and at special retreats and events.

A large scale piece called the Healing Garden will be available early 2014 to showcase the work of several survivors and mark the impact of this wonderful grant. A variety of Arts-in-Medicine workshops will continue to be offered at the Cancer Center supported through funds donated to the Cancer Wellness program.


Oncology Certified Nurse Linda Allen, RN, visits with a patient in Billings Clinic Cody’s infusion center.

Billings Clinic 43-County Service Area with Oncology Clinic and Physician Outreach

Locations

Riverton

Fremont

Casper

Powell

Park Cody

Hot Springs

Thermopolis

Bighorn

Lovell Greybull

Washakie Worland

Sheridan Sheridan

Johnson Buffalo

Campbell

Gillette

Crook

Lincoln Flathead

Sanders Lake

Glacier

Missoula

Ravalli

Granite

Deer Lodge

Toole

Pondera

Teton

Lewis & Clark

Cascade

Jefferson

Silver Bow

Madison

Gallatin

Park

Sweet Grass

Meagher Wheatland

Judith Basin

Chouteau

Libe

rty

Hill Blaine

Fergus

Golden Valley

Carbon Big Horn

Yellowstone

Musselshell

Petroleum

Phillips

Valley

Garfield

Rosebud

Powder River

Carter

Custer Fallon

Prairie Wibaux

Dawson

McCone

Richland

Roosevelt

Sheridan Daniels

Missoula

Anaconda

Butte

Dillon

Bozeman

Havre

Lewistown

Livingston

Big Timber Columbu

s Billings

Red Lodge

Hardin

Roundup

Forsyth Miles City Baker

Glendive

Sidney

Culbertson Wolf Point Glasgow

Primary

Secondary

Tertiary

Williams

Williston

Divide

McKenzie

Dickinson

Golden Valley B

illings

Dunn

Stark

Slope

Bowman Adams

Hettinger

Billings Clinic Oncology Sites Oncology Main Clinic Locations

Medical Oncology Outreach

Gynecologic Oncology Outreach

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In 2012, Billings Clinic added two new team members to our Pediatric Center, Dr. Courtney Lyle, MD, pediatric hematologist/oncologist, and Jill Wineinger, RN, BSN, pediatric nurse clinician. Since joining Billings Clinic, Dr. Lyle and Jill have worked with the Inpatient Cancer Care (ICC) team to develop expertise in providing inpatient oncology care for pediatric patients ages nine to 17 years old.

To prepare the staff to safely and effectively care for pediatric oncology patients, a robust education plan was developed. During the first part of 2013, Dr. Lyle presented education to staff on pediatric end-of-life care during the Hot Topics in Pediatrics Nursing workshop. In addition, she met with the ICC team and presented education on childhood cancers. This interactive education provided opportunities for staff to ask questions and feel more comfortable with the care of such a young group. Jill also provided several educational opportunities including “A Child-Centered Approach in a Healthcare Setting” which increased staff knowledge of pediatric growth and development.

Billings Clinic partnered with Rocky Mountain Hospital for Children in Denver, Colorado to obtain additional expertise in pediatric nursing education. Two pediatric nurses from Rocky Mountain Hospital for Children came to Billings Clinic and provided the Association of Pediatric Hematology/Oncology (APON)

Pediatric Chemotherapy and Biotherapy Provider Program for 21 ICC staff members. The same staff members are also now Pediatric Advanced Life Support (PALS) trained and certified.

The unit also obtained pediatric specific equipment to meet the medical needs of this patient population. The unit now has a special

emergency code cart for pediatric emergencies called a Broselow cart. Staff completed “Broselow Training – How to use Color Coding in Pediatric Emergencies”. Age-specific diversional activities were also acquired such as movies, videos, and electronic games.

System changes to the electronic medical record (EMR) were made to accommodate the special medical orders needed to care for this age population. Both Dr. Lyle and Jill worked with the oncology nurse informaticist to develop pediatric oncology orders in the EMR which outline evidence-based cancer treatment regimens for chemotherapy/biotherapy.

In September, a Pediatric Practice Advisory Committee (PPAC) was developed to streamline all pediatric care throughout the organization. This committee will allow current policies to be updated to better serve the pediatric population in the acute care setting.

With the support and training provided by both Dr. Lyle and Jill, ICC has admitted 12 patients ages nine – 15 in 2013, with an average length of stay of three-to-four days.

Inpatient Cancer Care: The Journey to Inpatient Pediatric Cancer Care

Dr. Courtney Lyle and Jill Wineinger, RN, (right) visit with ICC nurses who have been trained to provide pediatric cancer care.

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NAPBC AccreditationEarlier this year, Billings Clinic was granted three-year, full accreditation designation by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. The NAPBC is a consortium of professional organizations dedicated to the improvement of the care and monitoring of outcomes for patients with diseases of the breast. NAPBC accreditation signifies a facility’s dedication to providing the highest level of quality breast care through compliance with nationally established program standards. Standards set by the NAPBC ensure patients receiving care at a NAPBC-accredited center have access to comprehensive and coordinated breast care, state-of-the-art services, and a multidisciplinary team approach.

Reger Family Center for Breast HealthThe 4,300-square-foot Reger Family Center for Breast Health opened in October 2013 on the second floor of the Billings Clinic Cancer Center. The center offers complete breast diagnostic services in a private, comfortable environment. Features include a spa-like atmosphere, specialty coffee and comfortable seating in the lobby, private changing rooms with doors that enter directly to the mammography suite, and warm spa robes or capes.

Mammography, breast ultrasound, stereotactic breast biopsy, and bone densitometry (DEXA scan) suites are all located together so that

comprehensive evaluations can be completed in a single location. Additionally, tomosynthesis technology, which provides the highest resolution mammography to detect early breast cancers, is now available at Billings Clinic.

A retail Breast Boutique is also housed within the Reger Family Center for Breast Health. The Breast Boutique has two private fitting rooms and the region’s only experienced certified fitter to assist women with pre- and post-breast surgery needs. The boutique, staffed Monday through Friday, is open to anyone in need of mastectomy and breast-cancer merchandise including bras, prostheses, camisoles, scarves, hats, lotions, and other personal care items. One improvement this boutique brings to the community is the ability for Billings Clinic to bill purchases directly to patients’ insurance, rather than patients having to pay for products upfront and then be reimbursed.

iPad Donation Helps Patients Stay ConnectedUnited Luv, a family t-shirt company, gifted nine iPads to Billings Clinic for oncology patient use during lengthy cancer treatments. This gift was in memory of one of the founding members of United Luv whose vision was to provide iPads to area cancer centers to help others battling cancer stay connected with family and friends during treatment. This very special gift was matched by the Billings Clinic Foundation for a total of 18 iPads available to patients receiving cancer treatment in the Infusion Center, Inpatient Cancer Care unit, and Pediatric Oncology.

New Programs

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Welcome New Physicians

Dr. Robert JosephBillings Clinic welcomed Dr. Robert Joseph to our Billings Clinic Cody Oncology and Infusion Center as a medical oncologist and hematologist in March 2013. Dr. Joseph attended medical school at the University of Illinois School of Medicine in Chicago,

Illinois, and finished the Straight Medical Internship in Los Angeles County, University of Southern California (LAC/USC). He completed his residencies in hematology/oncology at Veterans Affairs Wadsworth, University of California, Los Angeles Medical Centers and at LAC/USC Medical Center.

Dr. Michelle ProperBillings Clinic welcomed Dr. Michelle Proper to our Cancer Center as a Radiation Oncologist in October 2013. Dr. Proper completed medical training at University of Illinois at Chicago – College of Medicine, and her residency in Radiation Oncology

at University of Colorado, Denver, Colorado. Dr. Proper specializes in treating all types of cancer with radiation therapy, but has a special interest in treating breast, gynecologic, and gastrointestinal cancers. Her prior research involved Stereotactic Body Radiation Therapy, which is used at Billings Clinic for certain cancers.

Dr. Pamela SmithBillings Clinic welcomed Dr. Pamela Smith to our Cancer Center as a Medical Oncologist and Hematologist in September 2013. Dr. Smith completed medical training and residency at The University of Colorado Health Sciences Center, Denver, Colorado, and her fellowship in

Hematology and Oncology at Tufts Medical Center, Boston, Massachusetts.

Dr. Erin StevensBillings Clinic welcomed Dr. Erin Stevens to our Cancer Center as a Gynecologic Oncologist in August 2013. Dr. Stevens completed medical training at New York Medical College in Valhalla, New York, her residency at Stony Brook Medical Center in Stony Brook, New York, and her

fellowship in Gynecologic Oncology at The State University of New York (SUNY) Downstate Medical Center in Brooklyn, New York. She also spent time serving OB /GYN patients in Miles City. Dr. Stevens specializes in the diagnosis and treatment for all types of female reproductive cancers and pre-cancerous conditions.

Dr. Venu ThirukondaBillings Clinic welcomed Dr. Venu Thirukonda to our Cancer Center as a medical oncologist and hematologist in July 2013. Dr. Thirukonda completed medical training at Madurai Medical College in Madurai, India, and his fellowship in hematology and oncology at Montefiore

Medical Center, Albert Einstein College of Medicine in Bronx, New York.

We want to extend a grand welcome to the new oncologists who joined Billings Clinic in 2013. The clinical contributions they bring to cancer care in the region are truly outstanding.

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2013 Patient Care Evaluation StudyUse of Herceptin in HER-2 Positive Breast CancerThe Billings Clinic Cancer Center embarked on a study in 2013 to evaluate the use of Herceptin in invasive HER-2 positive breast cancer cases (N=81) between 2009 and 2012. In addition, stage at diagnosis and overall survival for all Billings Clinic breast cancer cases was compared to national survival rates using data from the National Oncology Data Base (NODB), National Cancer Data Base (NCBC), and Montana Cancer Registry (MCR).

BackgroundBreast cancer is the most common malignancy diagnosed in women and the second leading cause of cancer-related deaths in women (Figure 1). These statistics shed light onto the importance of continued focus on quality outcomes for this wide-reaching disease.

HER-2, or human epidermal growth factor receptor 2, is overexpressed in about 20% of breast cancers. Targeting HER-2 with the monoclonal antibody trastuzumab (Herceptin) improves survival in both early-stage and advanced breast cancer (Trastuzumab plus Adjuvant Chemotherapy for Operable HER2-Positive Breast Cancer; Edward Romond, et al; N Engl J Med2005:353:1673.

Figure 1: Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths By Sex, United States, 2013. Seigel, Naishadham, & Jemal. CA: A Cancer Journal for Clinicians, 2013. Vol 63, No. 1, pp. 11-30.

Estimates are rounded to the nearest 10 and exclude basal cell and squamous cell skin cancers and in situ carcinoma except urinary bladder.

10

Patient Care Evaluation Study (Cont’d)

Randomized Phase 2 Trial of Trastuzumab Combined With Docetaxel in Patients with HER2-Positive Metastatic Breast Cancer; M Martin et al; J Clin Onc 2005:23;4265). Women with early stage (stages I-III) breast cancer with HER-2 overexpression should receive treatment with chemotherapy and Herceptin as adjuvant therapy. Furthermore, clinical trials have shown survival improvement in node-positive and high-risk node-negative (tumor > 1cm) cancers when Herceptin is added to chemotherapy. For node-negative patients with tumors smaller than 1cm, there are no randomized clinical trial data. Based on the increased risk of recurrence for tumors that overexpress HER-2, the National Comprehensive Cancer Network (NCCN) recommends the use of Herceptin and chemotherapy for small tumors (Figure 2).

Because of potential cardiac toxicity from Herceptin and side effects from chemotherapy, not all patients are candidates for systemic treatment. Patients with metastatic breast cancer and HER-2 positive disease also benefit from Herceptin therapy as a single agent or when added to hormonal therapy or chemotherapy. Figure 2: NCCN Guidelines for Herceptin Use in HER-2 Positive Early Stage Breast Cancer.

NCCN Guidelines for Herceptin Use in HER-2 Positive Early Stage Breast Cancer

Hormone Receptor Positive

Tumor Size Node Status Treatment*

≤ 0.5cm neg H

≤ 0.5cm pos, <2mm H, T ± C

≥ 0.6cm neg H, T, C

Any pos H, T, C

Hormone Receptor Negative

Tumor Size Node Status Treatment*

≤ 0.5cm neg none

≤ 0.5cm pos, <2mm T + C

≥ 0.6cm neg T + C

Any pos T + C

* T = trastuzumab (herceptin) H = hormone therapy C = chemotherapy

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Quality Measures and OutcomesIn an effort to assess quality and improve outcomes, the Billings Clinic Cancer Committee undertook a retrospective review of Billings Clinic cancer registry patients with invasive HER-2 positive breast cancer diagnosed between 2009 and 2012 and the use of Herceptin. Additionally, stage at diagnosis and overall survival for all breast cancers diagnosed at Billings Clinic was compared to national statistics including data obtained from the NODB, NCBC, and MCR. A total of 762 patients were diagnosed with breast cancer at Billings Clinic between 2009 and 2012, of which 81 were HER-2 positive invasive breast cancers (Graph 1).

Of the 81 patients with HER-2 positive invasive breast cancer, 65 patients (80.2%) received Herceptin as part of their systemic therapy (Graph 2).

183

241

184154

24 25 18 150

50

100

150

200

250

2009 2010 2011 2012

Number of Breast Cancers Number of HER2+ Breast Cancers

* One HER-2 positive patient did not have an invasive breast cancer

Graph 1: This shows the annual distribution by year of diagnosis for the 762 breast cancers and 82 HER-2 positive cases diagnosed during the years 2009-2012. Note one of the HER-2 positive cases reported during this timeframe was not an invasive breast cancer.

Billings Clinic Breast Cancer Patients Diagnosed 2009 - 2012

65

16Yes

No

Graph 2: This shows Herceptin was given for Billings Clinic cancer patients diagnosed 2009-2012 with HER-2 positive invasive breast cancer in 80.2% of cases. In 9 additional cases, Herceptin was discussed; this equates to 91.4% of HER-2 positive invasive breast cancer patients either received or were considered for Herceptin.

Herceptin Given for Billings Clinic Patients Diagnosed 2009 - 2012 with HER-2 Positive Invasive Breast Cancer

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Reasons identified as to why Herceptin was not given to 16 HER-2 positive invasive breast cancer patients included (Graph 3):

• 5 patients declined• 3 patients had no follow-up care at Billings Clinic• 3 patients enrolled in a clinical trial in which they received

lapatinib instead• 1 patient died within 3 days of diagnosis• 1 patient had significant comorbidities which precluded systemic

therapy• 1 patient was treated with hormone therapy alone because of

advanced age (93 years old with metastatic disease)• 1 patient had a tumor that was 95% HER-2 negative and only 5%

HER-2 positive• 1 patient with no apparent reason

Additionally, adjuvant Herceptin use in early stage invasive breast cancer patients at Billings Clinic was reviewed based on tumor size, nodal status, and estrogen receptor status (Figure 3).

Graph 3: This graph shows 31% of HER-2 positive invasive breast cancer patients did not receive Herceptin due to their own choice; 19% did not pursue follow-up care beyond diagnosis; 19% received Lapatinib on clinical trial; and the other 31% due to a variety of other single-cause reasons.

Reasons HER-2 Positive Invasive Breast Cancer Patients Did Not Receive Herceptin (Diagnosed 2009-2012)

5

3

3

1

1

1

11

Unknown

DeclinedNo follow-up careLapatinib givenDied w/i 3 dComorbidities

95% neg/5% posHT only

Figure 3: This shows 76% of hormone receptor (HR) positive patients and 100% of HR negative patients with smaller tumors and node negative tumors received Herceptin per NCCN guidelines. 91% of HR positive and 71.4% of HR negative node positive patients received Herceptin.

Invasive Breast Cancer - Hormone Receptor Positive

# Patients # Patients Receiving Herceptin

pT1, PT2, pT3 and pN0 or pN1mi

29 22

Tumor ≤ 0.5 cm or microinvasive, pN0

4 3

Tumor ≤ 0.5 cm or microinvasive, pN1mi

Tumor 0.6 - 1.0 cm 6 6

Tumor > 1 cm 19 13

Node positive 22 20

Node X 2 1

Node blank 8 4

Invasive Breast Cancer - Hormone Receptor Negative

# Patients # Patients Receiving Herceptin

pT1, PT2, pT3 and pN0 or pN1mi

11 11

Tumor ≤ 0.5 cm or microinvasive, pN0

0 0

Tumor ≤ 0.5 cm or microinvasive, pN1mi

0 0

Tumor 0.6 - 1.0 cm 3 3

Tumor > 1 cm 8 8

Node positive 7 5

Node X 1 1

Node blank 2 1

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Stage at Diagnosis and Survival ComparisonGraphs 4, 5, and 6 depict Billings Clinic overall 5-year survivorship for breast cancer by stage compared to the NODB, MCR, and NCDB respectively. Billings Clinic overall survival for breast cancer is comparable to survival rates from these regional and national benchmarks

Graphs 7 and 8 depict stage at diagnosis for breast cancers diagnosed at Billings Clinic versus all other hospitals in the NODB. A lower rate of Stage 0 and slightly higher rate of Stage III breast cancers was noted for Billings Clinic as compared to all other hospitals in the NODB, although progress was noted in 2012 with an increasing rate of stage 0 cancers diagnosed. To further investigate this, stage at diagnosis was also compared using the NCDB whereby similar trends were found when comparing to other hospitals in Montana, as well as the ACS’s Great West comprehensive cancer center program (Graphs 9 and 10).

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Year 1 Year 2 Year 3 Year 4 Year 5

Perc

ent S

urvi

val

BC Stage I

BC Stage II

BC Stage III

BC Stage IV

MT Stage IV

MT Stage I

MT Stage II

MT Stage III

Overall 5-Year Survival for Breast Cancer CasesBillings Clinic vs. Montana Cancer Registry

2009-2011

Graph 5: This demonstrates the 5-year survival rate by stage of disease for all Billings Clinic breast cancers (stages I-IV) as compared with the Montana Cancer Registry.

Overall 5-Year Survival for Breast Cancer CasesBillings Clinic vs. National Oncology Database

2009-2012

Graph 4: This demonstrates the 5-year survival rate by stage of disease for all Billings Clinic breast cancers (stages 0-IV) as compared with the National Oncology Data Base.

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0-12 mo 12-24 mo 24-36 mo 36-48 mo 48-60 mo 60+ mo

Perc

ent S

urvi

val

BC Stage I

BC Stage 0

BC Stage II

BC Stage III

BC Stage IV

NODB Stage IV

NODB Stage I

NODB Stage 0

NODB Stage II

NODB Stage III

Overall 5-Year Survival for Breast Cancer CasesBillings Clinic vs. National Cancer Database

2003-2006

Graph 6: This demonstrates the 5-year survival rate by stage of disease for all Billings Clinic breast cancers (stages 0-IV) as compared with the National Cancer Data Base.

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Dx 1 Year 2 Year 3 Year 4 Year 5 Year

Perc

ent S

urvi

val

BC Stage I

BC Stage 0

BC Stage II

BC Stage III

BC Stage IV

NCDB Stage IV

NCDB Stage I

NCDB Stage 0

NCDB Stage II

NCDB Stage III

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ConclusionsThus, Billings Clinic Cancer Center outcomes for the treatment of breast cancer compare favorably to national outcomes. Specifically, use of Herceptin in HER-2 positive invasive breast cancers is highly concordant with the NCCN guidelines, based on hormone receptor status, tumor size, and nodal status. About 10-11% of patients with breast cancer treated at the Billings Clinic had HER-2 positive invasive breast cancer, and the majority of these patients received Herceptin (80%). Of the 20% of patients who did not receive Herceptin, 6% refused Herceptin as recommended by the

oncologist, 4% received lapatinib as alternate treatment according to clinical trial enrollment, and 4% did not pursue additional follow-up beyond diagnosis. In addition, stage at diagnosis and overall survival are similar to national benchmarks, with slight improvements noted of recent at Billings Clinic with increased diagnosis of stage 0 breast cancers. This is an area that will need to continue to be monitored in order to ensure this upward trend continues so that stage at diagnosis is more closely aligned with national benchmarks.

05

101520253035404550

BC 2009 BC 2010 BC 2011 BC 2012

0 I II III IV 88 Unknown

11.78.7

11.96 13.86

40.96 38.7

45.6539.76

2528.26

24.46 26.51

11.17 11.74 11.417.83

2.13 3.91 3.26 4.820.6

9.04 8.73.26

6.63

0

10

20

30

40

50

Other MT 2009 Other MT 2010 Other MT 2011

0 I II III IV N/A Unknown

18.86 18.27 18.74

39.84 41.9245.01

27.64

21.53 20.89

8.29 9.46 9.98

2.28 4.08 4.613.09.33 .77

05

101520253035404550

All Other NODB 2009 All Other NODB 2010 All Other NODB 2011 All Other NODB 2012

0 I II III IV 88 Unknown

18.76 18.85 18.53 18.43

37.82 39.4 41.07 42.1

25.07 24.63 25.23 24.7

9.36 9.14 8.43 8.423.87 3.76 3.82 3.68

.09.04.1.084.94 4.12 2.87 2.57

0

10

20

30

40

50

Other Great West 2009 Other Great West 2010 Other Great West 2011

0 I II III IV N/A Unknown

21.13 19.79 19.61

39.342.4 43.72

23.82 22.44 22.74

8.38 9.1 8.723.52 3.77 3.773.77 2.37 1.36.13.07 .07

Graphs 7 and 8: This demonstrates lower rates of Stage 0 and slightly higher rates of Stage III breast cancer diagnosed at Billings Clinic as compared to all other hospitals in the NODB.

Graphs 9 and 10: Similar findings are noted when looking at data within the NCDB; Billings Clinic has a lower percentage of breast cancers diagnosed at Stage 0 and slightly higher rates of Stage III.

Stage at Diagnosis for Breast Cancers at Billings Clinic2009-2012

Stage at Diagnosis for Breast Cancers at All Other Montana Hospitals in National Cancer Database

2009-2011

Stage at Diagnosis for Breast Cancers in the NODB2009-2012

Stage at Diagnosis for Breast Cancers at All Other ACS Great West Region Comprehensive Cancer Center Programs in National Cancer Database

2009-2011

15

Cancer Registry Milestones

In March, the Registry initiated use of an automated, case-matching file importation process for its encounter-based case finding system, reducing manual processing time significantly. Following, in July, the Registry also fully implemented a second case-finding methodology (E-Path) that utilizes artificial medical intelligence to electronically review pathology reports. This state-of-the-art software has likewise contributed to manual processing reductions and has produced an added benefit of locating eligible patients more quickly for clinical trials. The E-Path software utilized by the cancer registry is a product of Artificial Intelligence in Medicine, Inc., an information technology and software development company based in Toronto, Ontario.

To maintain their educational credentials, our certified tumor registrars participate in a number of self-study activities throughout the year, as well as attend state and national meetings sponsored by their respective professional

organizations, the Montana Cancer Registrars Association (MCRA) and National Cancer Registrars Association (NCRA). This year, the registrars traveled to Bozeman for the statewide meeting and one attended the NCRA annual meeting in San Francisco. These events provide important opportunities for networking, sharing “best practices”, and keeping abreast of the latest developments in the field.

The Registry continues to actively participate in the Commission on Cancer’s Rapid Quality Reporting System (RQRS) and provides support for other quality initiatives such as ongoing monitoring of quality measures for continued recognition as an NAPBC accredited breast center. It also just concluded participation in the National Cancer Institute-sponsored PROSSES study, and has begun participation in Total Cancer Care® through the Moffitt Cancer Center in Tampa, Florida.

This has been a year of significant technological advances for the Billings Clinic Cancer Registry.

(l-r) Cancer Registrars(back row) Kerrie Robertson, Lori Frank, and Technical Assistant Lee Ann Carranco. (front row) Marcia Schermerhorn and Barb Shevela

16

2012 Primary Site Table -- Cancer Cases

ORAL CAVITY & PHARYNX 34 33 20 14 25 5 2 8 4 1 17 0 0 1

Lip 3 3 1 2 3 0 1 2 0 0 0 0 0 0

Tongue 10 10 5 5 8 2 1 2 1 1 4 0 0 1

Salivary Glands 3 3 2 1 3 0 0 2 0 0 1 0 0 0

Floor of Mouth 1 1 0 1 1 0 0 1 0 0 0 0 0 0

Gum & Other Mouth 3 2 1 2 2 1 0 1 0 0 1 0 0 0

Nasopharynx 1 1 1 0 1 0 0 0 0 0 1 0 0 0

Tonsil 10 10 8 2 9 1 0 0 2 0 8 0 0 0

Hypopharynx 3 3 2 1 2 1 0 0 1 0 2 0 0 0

DIGESTIVE SYSTEM 217 208 111 106 142 75 4 17 42 65 55 0 5 20

Esophagus 23 23 18 5 9 14 1 3 3 6 8 0 0 2

Stomach 17 16 9 8 6 11 0 2 2 5 5 0 1 1

Small Intestine 12 12 3 9 11 1 0 0 1 7 3 0 0 1

Colon Excluding Rectum 66 62 34 32 56 10 2 7 17 19 13 0 0 4

Cecum 9 9 4 5 9 0 0 1 3 5 0 0 0 0

Appendix 4 4 2 2 3 1 0 0 1 0 2 0 0 1

Ascending Colon 17 16 9 8 15 2 0 3 5 4 3 0 0 1

Hepatic Flexure 6 5 4 2 4 2 0 1 1 1 1 0 0 1

Transverse Colon 4 4 2 2 2 2 0 0 3 0 1 0 0 0

Descending Colon 2 2 0 2 2 0 1 0 1 0 0 0 0 0

Sigmoid Colon 21 20 12 9 18 3 1 1 3 9 5 0 0 1

Large Intestine, NOS 3 2 1 2 3 0 0 1 0 0 1 0 0 0

Rectum & Rectosigmoid 42 40 24 18 36 6 1 4 11 11 9 0 0 4

Rectosigmoid Junction 7 7 3 4 5 2 0 1 1 2 3 0 0 0

Rectum 35 33 21 14 31 4 1 3 10 9 6 0 0 4

Anus, Anal Canal & Anorectum 4 2 1 3 3 1 0 0 1 1 0 0 0 0

Liver & Intrahepatic Bile Duct 9 9 2 7 4 5 0 0 1 3 2 0 2 1

Liver 7 7 2 5 2 5 0 0 1 2 1 0 2 1

Intrahepatic Bile Duct 2 2 0 2 2 0 0 0 0 1 1 0 0 0

Gallbladder 4 4 1 3 1 3 0 0 1 0 3 0 0 0

Other Biliary 4 4 3 1 3 1 0 0 1 2 0 0 0 1

All CasesPrimary Site* Analytic

Cases M F Stg 0Alive Stg I Stg II Stg III Stg IV*** N/A

** Exp

***** Unk

**** NSR

17

Cont’d -- Cancer Cases2012 Primary Site Table

DIGESTIVE SYSTEM - cont’d

Pancreas 22 22 13 9 2 20 0 1 4 5 8 0 0 4

Retroperitoneum 1 1 1 0 1 0 0 0 0 1 0 0 0 0

Peritoneum, Omentum & Mesentery 11 11 0 11 8 3 0 0 0 5 4 0 0 2

Other Digestive Organs 2 2 2 0 2 0 0 0 0 0 0 0 2 0

RESPIRATORY SYSTEM 176 172 90 86 98 78 2 43 19 32 71 0 0 5

Larynx 10 10 9 1 9 1 1 3 2 1 3 0 0 0

Lung & Bronchus 166 162 81 85 89 77 1 40 17 31 68 0 0 5

BONES & JOINTS 1 1 0 1 1 0 0 0 0 0 0 0 0 1

SOFT TISSUE INCLUDING HEART 6 5 5 1 5 1 0 1 3 0 0 0 0 1

SKIN - EXCLUDING BASAL & SQUAMOUS 162 157 102 60 152 10 90 46 5 6 1 0 1 8

Melanoma - Skin 156 152 98 58 148 8 90 44 5 5 1 0 0 7

Other Non-Epithelial Skin 6 5 4 2 4 2 0 2 0 1 0 0 1 1

BREAST 172 168 0 172 166 6 24 75 43 12 12 0 1 1

FEMALE GENITAL SYSTEM 267 190 0 267 244 23 1 102 11 41 22 0 3 10

Cervix Uteri 84 26 0 84 80 4 0 9 1 11 4 0 0 1

Corpus & Uterus, NOS 116 115 0 116 106 10 1 80 6 9 13 0 1 5

Corpus Uteri 108 107 0 108 101 7 1 76 4 9 11 0 1 5

Uterus, NOS 8 8 0 8 5 3 0 4 2 0 2 0 0 0

Ovary 41 38 0 41 34 7 0 5 4 20 4 0 2 3

Vagina 5 2 0 5 5 0 0 1 0 0 0 0 0 1

Vulva 21 9 0 21 19 2 0 7 0 1 1 0 0 0

MALE GENITAL SYSTEM 166 142 166 0 158 8 0 39 54 22 12 0 0 15

Prostate 163 139 163 0 155 8 0 36 54 22 12 0 0 15

Testis 3 3 3 0 3 0 0 3 0 0 0 0 0 0

URINARY SYSTEM 122 113 87 35 105 17 34 42 8 12 8 0 0 9

Urinary Bladder 61 54 50 11 50 11 32 9 4 3 3 0 0 3

Kidney & Renal Pelvis 58 56 37 21 54 4 1 33 4 8 4 0 0 6

Ureter 3 3 0 3 1 2 1 0 0 1 1 0 0 0

All CasesPrimary Site* Analytic

Cases M F Stg 0Alive Stg I Stg II Stg III Stg IV*** N/A

** Exp

***** Unk

**** NSR

18

Cont’d -- Cancer Cases2012 Primary Site TableAll CasesPrimary Site

* Analytic Cases M F Stg 0Alive Stg I Stg II Stg III Stg IV

*** N/A

** Exp

***** Unk

**** NSR

EYE & ORBIT 2 1 1 1 1 1 0 0 0 0 0 0 1 0

BRAIN & OTHER NERVOUS SYSTEM 51 46 13 38 37 14 0 0 0 0 0 0 46 0

Brain 20 18 8 12 11 9 0 0 0 0 0 0 18 0

Cranial Nerves Other Nervous System 31 28 5 26 26 5 0 0 0 0 0 0 28 0

ENDOCRINE SYSTEM 78 73 35 43 76 2 0 36 3 4 6 0 23 1

Thyroid 52 50 19 33 51 1 0 36 3 4 6 0 0 1

Other Endocrine including Thymus 26 23 16 10 25 1 0 0 0 0 0 0 23 0

LYMPHOMA 59 55 30 29 49 10 0 13 9 18 12 0 0 3

Hodgkin Lymphoma 9 8 4 5 9 0 0 0 5 3 0 0 0 0

Hodgkin - Nodal 8 8 4 4 8 0 0 0 5 3 0 0 0 0

Hodgkin - Extranodal 1 0 0 1 1 0 0 0 0 0 0 0 0 0

Non-Hodgkin Lymphoma 50 47 26 24 40 10 0 13 4 15 12 0 0 3

NHL - Nodal 37 34 19 18 27 10 0 4 3 14 10 0 0 3

NHL - Extranodal 13 13 7 6 13 0 0 9 1 1 2 0 0 0

MYELOMA 22 22 7 15 14 8 0 0 0 0 0 0 22 0

LEUKEMIA 46 43 27 19 35 11 0 0 0 0 0 0 43 0

Lymphocytic Leukemia 25 23 16 9 20 5 0 0 0 0 0 0 23 0

Acute Lymphocytic Leukemia 2 2 1 1 2 0 0 0 0 0 0 0 2 0

Chronic Lymphocytic Leukemia 20 18 12 8 16 4 0 0 0 0 0 0 18 0

Other Lymphocytic Leukemia 3 3 3 0 2 1 0 0 0 0 0 0 2 0

Myeloid & Monocytic Leukemia 17 17 9 8 11 6 0 0 0 0 0 0 17 0

Acute Myeloid Leukemia 13 13 6 7 7 6 0 0 0 0 0 0 13 0

Chronic Myeloid Leukemia 4 4 3 1 4 0 0 0 0 0 0 0 4 0

Other Leukemia 4 3 2 2 4 0 0 0 0 0 0 0 3 0

Other Acute Leukemia 2 2 1 1 2 0 0 0 0 0 0 0 2 0

Aleukemia, Subleukemic & NOS 2 1 1 1 2 0 0 0 0 0 0 0 1 0

MESOTHELIOMA 5 5 3 2 1 4 0 2 2 0 1 0 0 0

MISCELLANEOUS 52 48 33 19 28 24 0 0 0 0 0 0 48 0

TOTAL 1,638 1,482 730 908 1,341 297 157 424 203 213 217 0 193 75

Exclusions: Not Male and Not Female 0 0

* Analytic: Patients diagnosed and/or received any of first course treatment at Billings Clinic.

** Exp: Expired *** N/A: Case is not eligible for staging. An AJCC staging scheme has not been developed for this site or histology is excluded from an AJCC site scheme.

**** NSR: No staging required ***** Unk: Cases that do not have enough information to stage or the physician considered it unstageable.

19

According to the most recent and available national data from SEER (Surveillance Epidemiology and End Results) for years 2006-2010 inclusive, the median age at diagnosis for all cancer sites is age 66 for men and age 65 for women. The data above for Billings Clinic shows a similar pattern with the median age at diagnosis for men at 66 and for women at 64.

The graph shows a small decline in analytic cases in 2012 after 4 consecutive years of increase (orange bar). This pattern is not unlike the experience of other cancer programs regionally and nationally and may reflect continuing weakness in the national economy, as well as changes in oncology practice patterns, including those related to the diagnosis and treatment of prostate cancer.

Analytic cases are those diagnosed and/or receiving part or all of the entire first course of treatment at Billings Clinic. Non-analytic cases (lavender bar) include those who may only receive follow-up care or treatment for a recurrence at Billings Clinic. The total number of cases for each year, inclusive of analytic and non-analytic cases, is noted at the top of each bar or column.

Cancer Registry

Analytic vs. Non-Analytic Cases - Last 5 YearsAge at Diagnosis by GenderAnalytic Cases, Accession Year 2012

090+80-8970-790-29 30-39 40-49 50-59 60-69

Age Groups

Num

ber o

f Cas

es

50

100

150

200

250

Male

Female

1911

2819

81

35

166

105

233224

172184

104

78

8 15

02008 2009 2010 2011 2012

200

400

600

800

1000

1200

1400

1600

1800

Non-Analytic CasesAnalytic Cases

1616 16081680

17581638

176 155178

183156

1440 14531502

15751482

Registry Accession by Year of First Contact

Num

ber o

f Cas

es

20

Cancer Registry (Cont’d)

The bar graph above shows a changing pattern over time for the primary diagnosis of breast cancer for women at Billings Clinic. The numbers at the right end of each bar indicate actual number of cases and total percentage of this cancer for each year.

The bar graph above shows fluctuation over time for the primary diagnosis of prostate cancer for men at Billings Clinic. The numbers at the right end of each bar indicate actual number of cases and total percentage of this cancer for each year.

Breast Cancer over 5 YearsNumber and Percent of Total Female Analytic Cases

Prostate Cancer over 5 YearsNumber and Percent of Total Male Analytic Cases

0

2008

2012

2011

2010

2009

50 100 150 200 250

165

168

186

234

184

21% T

21% T

22% T

29% T

23% T

Acc

essi

on Y

ear

Number of Cases

0

2008

2012

2011

2010

Acc

essi

on Y

ear

Number of Cases

2009

50 100 150 200 250

136

139

206

163

174

20% T

21% T

27% T

24% T

27% T

21


The stacked graph [above] shows a 5 year trend for the primary cancers seen at Billings Clinic, irrespective of gender. The American Cancer Society (ACS) ranks breast, prostate, lung, melanoma and colon cancers as the top 5 cancers in terms of incidence nationally. Our rankings are similar to those of ACS with one exception: uterine cancer ranks 6th in terms of numbers of cases seen at Billings Clinic while bladder cancer ranks in 6th place nationally according to ACS estimates. Our higher rate of uterine cancers treated is likely reflective of our widely recognized regional expertise with gynecological cancers, having a dynamic treatment program led by a board certified gynecologic oncologist, trained in advanced robotic surgical techniques.

Trends in Cancers Seen at Billings Clinic Over Last 5 Years

0

100

200

300

400

500

600

700

800

900

1000

2008 2009 2010 2011 2013

Calendar Year

Num

ber o

f Cas

es

Uterus

Prostate

Breast

Melanoma

Lung

Colon

22


Top Five Cancers - FemaleNational data from the American Cancer Society (years 2010-2012) indicate the leading cancers for women remain breast (28-31%), lung (14%), and colorectal (9-10%) cancers. Billings Clinic data for the last 5 years (2008-2012) for women is shown in the pie charts herein. While breast cancer remains our primary female cancer, representing approximately 22-29% of all female cancers at Billings Clinic, uterine cancer is second (9-13%) followed by lung cancer (8-12%). This variation from national statistics is likely reflective of our widely recognized expertise in gynecologic cancers, having the only such program in Montana, Wyoming and North Dakota.

Year 2008Based on Analytic Cases N = 762





Breast18423%

Uterus85

11%

Lung77

10%

Melanoma607%

Colorectal648%

All Others33642%

Breast23429%

Uterus739%

Lung688%

Melanoma668%

Colorectal628%

All Others31038%

Breast18622%

Uterus11113%

Lung95

11%Melanoma

587%

Colorectal516%

All Others34441%

Breast16821%

Uterus11514%

Lung84

10%

Hematological709%

Melanoma587%

All Others31639%

Breast16522%

Uterus79

10%

Lung74

10%

Melanoma11215%

Colorectal598%

All Others27336%

23


Top Five Cancers - MaleA review of the most recent national data available from the American Cancer Society (years 2010-2012) indicates the primary 3 cancers for men have remained unchanged with prostate cancer in the lead for men (28-29% of all male cases) followed by lung (14-15%) and colorectal (9%) cancers. Statewide data over a five year period (2006-2010) from the Montana Central Tumor Registry reflects a similar pattern. Billings Clinic data shown in the pie charts herein for years 2008-2012 indicates a break from this pattern. While prostate cancer remains the primary male cancer at Billings Clinic, melanoma takes second place followed by lung cancer for men. This variance from national and state trends is likely a function of our recognized expertise as a resource and referral site for dermatology and specialized skin cancer therapies including Mohs surgery.



Year 2010Based on Analytic Cases N =688



Prostate17427%

Melanoma82

13%

Lung74

11%

Colorectal518%

Hematological498%

All Others21633%

Prostate16324%

Melanoma96

14%

Lung72

10%

Hematological578%

Colorectal599%

All Others24135%

Prostate13921%

Melanoma94

14%

Lung78

12%

Hematological599%

Colorectal548%

All Others24737%

Prostate13620%

Melanoma11617%

Lung67

10%

Hematological70

10%

Colorectal68

10%

All Others22032%

Prostate20628%

Melanoma81

11%

Lung80

11%

Hematological719%

Colorectal578%

All Others25434%

24

Awards, Presentations, Publications and Recognitions

Bette Bohlinger Leadership AwardSarah Porter-Osen, NCCCP Coordinator, received the 2013 Bette Bohlinger Leadership Award at the annual Montana Cancer Control Coalition (MTCCC) statewide meeting. Sarah has been actively

involved with MTCCC’s Screening and Early Detection team and is an advocate for programs which provide cancer screening for under- and un-insured women. Sarah also led MTCCC in the implementation of a successful statewide “Ask Me” campaign to encourage colorectal cancer screening. We are so proud of Sarah in her commitment to the cancer community.

25

Awards, Presentations, Publications and Recognitions (Cont’d)

Peer-Reviewed Publications• Alvarex, R.D., Gray, H.J., Timmins, P.F. III., Gibb, R.K., Edelson,

M., Fowler, J.M., Havrilesky, L.J., McCauley, D.L., Nash, J.D., Rahaman, J., Rash, J.K., Rodabaugh, K.J., Powell, M.A., Bristow, R.E., Brown, J.V., Tewari, D., Cliby, W.A., Anastasia, P., Robinson, W.R. III., Shahin, M.S., Cantrell, L.A., Cloven, N.G., Gold, M.A., Hope, J.M., Muntz, H.G., Sorosky, J.I., Elkas, J.C., Frumovitz, M.M., Jewell, E., Spillman, M.A., & Naumann, R.W. (2013). We need a new paradigm in gynecologic cancer care: SGO proposes solutions for delivery, quality and reimbursement policies. Gynecologic Oncology, 129(1), 3-4.

• Brant, J.M. (2013). Breathlessness with pulmonary metastases: A multimodal approach. Journal of the Advanced Practitioner in Oncology, 4(6), 415-422.

• Brant, J.M. (Ed). (2013). Advances in the management of breakthrough cancer pain. Pain Management Nursing/Seminars in Oncology Nursing. Medical Meeting Reporter. St Louis: Elsevier.

• Brant, J.M., & Hall, B. (2013). Taste and smell alterations and anorexia and cachexia in cancer. In D. Camp-Sorrell and B. Hawkins InPractice etextbook.

• Brant, J.M., & Wickham, R. (Eds). (2013). Statement on the Scope and Standards of Oncology Nursing Practice. Pittsburgh: ONS Press.

• Forsythe, L.P., Rowland, J.H., Padgett, L., Blaseg, K., Siegel, S.D., Dingman, C.M., & Gillis, T.A. (2013). The cancer psychosocial care matrix: A community-derived evaluative tool for designing quality psychosocial cancer care delivery. Psycho-Oncology, 22(9), 1952-1963.

• Leshchenko, V., Kuo, P.Y., Jiang, Z., Thirukonda, V.K., & Parekh, S. (2013). Integrative genomic analysis of Temozolomide resistance in Diffuse Large B Cell Lymphoma. Clinical Cancer Research, [epub ahead of print].

• Lillington, L., Scaramuzzo, L., Friesse, C., Sein, E., Harrison, K., LeFebrvre, K., & Fessele, K. (2013). Improving oncology nursing practice one patient, one nurse, one day at a time: Design and evaluation of a quality education workshop for oncology nurses. Clinical Journal of Oncology Nursing, 17(6), 584-587.

• Lyle, C.A., Gibson, E., Lovejoy, A., & Goldenberg, N.A. (2013). Acute prognostic factors for post thrombotic syndrome in children with limb DVT: A bi-institutional cohort study. Thrombosis Research, 131 (1): 37-41.

• Lyle, C.A., & Crawford, J.R. (2013). Neuro-diagnostic principles. In R.F. Keating, J.T. Goodrich, & R.J. Packer Tumors of the Pediatric Central Nervous System (2nd Ed).

• Lyle, C.A., & Goldenberg, N.A. (2013). Venous thrombosis. In E.M. Da Cruz, D. Ivy, & J. Jaggers (Eds.) Pediatric and Congenital Cardiology, Cardiac Surgery, and Intensive Care.

• Nair, V.S., Keu, K.V., Luttgen, M.S., Kolatkar, A., Vasanawala, M., Kuschner, W., Bethel, K., Iagaru, A.H., Hoh, C., Schrager, J.B., Loo, B.W. Jr., Bazhenova, L., Nieva, J., Gambhir, S.S., & Kuhn, P. (2013). An observational study of circulating tumor cells and (18)F-FDG PET uptake in patients with treatment-naïve non-small cell lung cancer. PLoS One, 8(7), e6773.

• Newton, P., Mason, J., Bethel, K., Bazhenova, L., Nieva, J., Norton, L., & Kuhn, P. (2013). Spreaders and sponges define metastasis in lung cancer: A Markov chain Monte Carlo mathematical model. Cancer Research, 73(9), 2760-2769.

• Rule, P., & Brant, J.M. (2013). Monoclonal gammopathy of undetermined significance – Making it understandable to patients. Clinical Journal of Oncology Nursing, 17(6), 614-619.

26

• Salz, T., McCabe, M.S., Onstad, E.E., Shrujal, S.B., Deming, R.L., Franco, R.A., Glenn, L.A., Harper, G.R., JumonVille, A.J., Payne, R.M., Peters, E.A., Salner, A.L., Schallenkamp, J.M., Williams, S.R., Yiee, K., & Oeffinger, K.C. Survivorship care plans: Is there buy-in from oncology providers. Cancer (accepted for publication).

• Singh, L., & Stevens, E. (2013). Leg pain and gynecologic malignancy. Journal of Hospice & Palliative Medicine, 30(6), 594-600.

• Stevens, E., Aquino, J., Barrow, N., & Lee, Y.C. (2013). Ectopic production of human chorionic gonadotropin from a synovial sarcoma. Obstetrics & Gynecology, 121(2Pt2 S1), 468-471.

• Stevens, E., Pradhan, T., Chak, Y., & Lee, Y.C. (2013). A case of malignant transformation of endometriosis in a cesarean section scar. Journal of Reproductive Medicine, 58(3), 264-266.

• Weber, A. (2013). A nurse-led symptom management clinic. In J.M. Brant (Ed). Advances in the management of breakthrough cancer pain. Pain Management Nursing/Seminars in Oncology Nursing. Medical Meeting Reporter. St Louis: Elsevier.

• Weickhardt, A.J., Doebele, R.C., Purcell, W.T., Bunn, P.A., Oton, A.B., Rothman, M.S., Wierman, M.E., Mok, T., Popat, S., Bauman, J., Nieva, J., Novello, S., Ou, S.H., & Camidge, D.R. (2013) Symptomatic reduction in free testosterone levels secondary to crizotinib use in male cancer patients. Cancer, 119(13), 2383-2390.

• Zaren, H.A., Nair, S., Go, R.S., Enos, R.A., Lanier, K.S., Thompson, M.A., Zhao, J., Fleming, D.L., Leighton, J.C., Gribbin, T.E., Bryant, D.M., Carrigan, A., Corpening, J.C., Csapo, K.A., Dimond, E.P., Ellison, C., Gonzales, M.M., Harr, J.L., Wilkinson, K., & Denicoff, A.M. (2013). Early-phase clinical trials in the community: Results from the National Cancer Institute Community Cancer Centers Program early-phase working group baseline assessment. Journal of Oncology Practice, 9(2), e55-e61.

Published Abstracts from National Conferences• Blaseg, K., White, D., Schallenkamp, J.S., Stephens, C., Needham,

C.S., & Nieva, J. (2013). The effects of multi-disciplinary clinics on the variability in timeliness of care for lung cancer patients. American Society of Clinical Oncology annual meeting, Chicago, IL. Journal of Clinical Oncology, 31(18 suppl), e17533.

• Guitarte, C., Stevens, E., Abulafia, O., & Lee, Y.C. (2013). Glassy cell carcinoma of the cervix: A systematic review and meta-analysis. Gynecologic Oncology, 130(1), e149-e150.

• Nguyen, M.T., LaFargue, C., Karsy, M., Stevens, E., McKernan, S., Pua, T., Goerlick, C., Tedjarati, S., & Pradhan, T.S. (2013). Routine cystoscopy after robotic gynecologic oncology surgery: Increasing urinary injury detection or simply achieving medical-legal benefit? Gynecologic Oncology, 130(1), e60.

• Stevens, E., & Henretta, M.S. (2013). Beyond the dark side of the moon: Evaluating the quality of web-based information at the end of life. SGO 44th Annual Meeting on Women’s Cancer, Los Angeles, CA. Gynecologic Oncology, 130(1), e141.

• Stevens, E., Pardo-Maxis, C., Lee, Y.C. & Abulafia, O. (2013). Defining practice patterns: What is “standard” postoperative care? A survey of the SGO membership. Gynecologic Oncology, 130(1), e57-e58.

Poster Presentations at National Conferences• Anderson, C., Gradwohl, R., Nelson, L., & Brant, J.M. (2013). An

oncology specific preceptor program: A path to oncology nursing knowledge, commitment and retention. Oncology Nursing Society Annual Congress, Washington, DC.

• Blumberg, J., Stevens, E., Zachariah, P., & Ogburn, P. (2013). Cervidil and induction of labor: Do two Cervidils make a difference? ACOG Annual Clinical Meeting 2013, New Orleans, LA.


27

• Budnick, L., Herbert, W., Griffin, T., Swoboda, E., Stevens, E., & Ninivaggio, C. (2013). Web-based application of the perineal simulator as a tool for medical students and interns to learn perineal anatomy and obstetric laceration classification. APGO/CREOG, Phoenix, AZ.

• Ciemins, E.L., Brant, J.M., Kersten, D., Mullette, B., & Dickerson, D. (2013). A patient-centered strategy to palliative care: A qualitative approach. Academy Health, Washington, DC.

• Garretto, D., & Stevens, E. (2013). The significance of excess gestational weight gain and delivery lacerations. ACOG Annual Clinical Meeting, New Orleans, LA.

• Garretto, D., & Stevens, E. (2013). Validating a “term BMI” using mode of delivery, estimating blood loss, and neonatal weight. ACOG Annual Clinical Meeting, New Orleans, LA.

• Guitarte, C., Stevens, E., Abulafia, O., & Lee, Y.C. (2013). Glassy cell carcinoma of the cervix: A systematic review and meta-analysis. SGO 44th Annual Meeting on Women’s Cancer, Los Angeles, CA.

• Nguyen, M.T., LaFargue, C., Karsy, M., Stevens, E., McKernan, S., Pua, T., Goerlick, C., Tedjarati, S., & Pradhan, T.S. (2013). Routine cystoscopy after robotic gynecologic oncology surgery: Increasing urinary injury detection of simply achieving medical-legal benefit? SGO 44th Annual Meeting on Women’s Cancer, Los Angeles, CA.

• Nichols, K., Anderson, C., Gradwohl, R., & Brant, J.M. (2013). Prevention of cerebellar toxicity from cytosine-arabinoside (Ara-C): Development of a nurse educational training program and assessment protocol. Oncology Nursing Society Annual Congress, Washington, DC.

• Pett, M., Beck, S.L., Towsley, G.L., Berry, P.H., Brant, J.M., Smith, E.L., & Guo, J.W. (2013). Confirmatory factor analysis of the Pain Care Quality Survey (PainCQ©). Health Services Research, 48(3), 1018-1038.

• Stevens, E., Gartman, C., Michl, J., & Sarafraz-Yazdi, E. (2013). Evaluation of PNC-27 mediated toxicity in an intraperitoneal mouse model of human ovarian cancer. Western Association of Gynecologic Oncologists Annual Meeting, Seattle, WA.

• Stevens, E., & Henretta, M.S. (2013). Beyond the dark side of the moon: Evaluating the quality of web-based information at the end of life. SGO 44th Annual Meeting on Women’s Cancer, Los Angeles, CA.

• Stevens, E., Pardo-Maxis, C., Lee, Y.C., & Abulafia, O. (2013). Defining practice patterns: What is “standard” postoperative Care? A survey of the SGO membership. SGO 44th Annual Meeting on Women’s Cancer, Los Angeles, CA.

• Swoboda, E., & Stevens, E. (2013). Assessing the self confidence of graduating chief residents in performing hyperectomies by modality and type of surgical assistant. APGO/CREOG, Phoenix, AZ.

• Von Walstrom, G., Stevens, E., Fatehi, M., Salame, G., Lee, Y.C., Gorelick, C., & Economos, K. (2013). Clinical utility of a chemoresponse assay for gynecologic malignancies. Western Association of Gynecologic Oncologists Annual Meeting, Seattle, WA.

• Weber, A., Waitman, K., Blaseg, K., & Brant, J. (2013). A nurse-led symptom management clinic. Oncology Nursing Society Annual Congress, Washington, DC.


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Podium Presentations at National Conferences• Design and evaluation of a quality educational workshop for

oncology nurses Quality and Safety Education for Nurses, Atlanta, GA. Presented by: Leah Scaramuzzo, RN, MSN, AOCN®, Oncology Nurse Clinician

• Effective mentoring of resident-led research projects APGO/CREOG Annual Meeting, Phoenix, AZ. Presented by: Erin Stevens, MD, Gynecologic Oncology

• Evidence-based medicine: Why the reluctance to follow guidelines and data? APGO/CREOG Annual Meeting, Phoenix, AZ. Presented by: Erin Stevens, MD, Gynecologic Oncology

• Getting patients active: Using quality measures to drive practice change Oncology Nursing Society, Washington, DC. Presented by: Leah Scaramuzzo, RN, MSN, AOCN®, Oncology Nurse Clinician

• Integrating Cerner applications to deliver treatment summaries and survivorship plans Cerner Health Conference, Kansas City, MO. Presented by: Karyl Blaseg, RN, MSN, OCN®, Manager of Cancer Programs

• Overcoming opioid-induced oversedation in hospitalized patients: Nurse-driven research, quality improvement, and evidence-based practice National Magnet Conference, Orlando, FL. Presented by: Jeannine Brant, PhD, APRN, AOCN®, Nurse Scientist and Oncology Clinical Nurse Specialist

• Stomping cancer through culture Spirit of Eagles’ Changing Patterns of Cancer in Native Communities: Strength through Tradition and Science, Albuquerque, NM. Presented by: Shawna Cooper, Patient Advocate

• Surgical anatomy: Tips and tricks Downstate Annual OB/GYN Review Course, Brooklyn, NY. Presented by: Erin Stevens, MD, Gynecologic Oncology

• Telemedicine and telesurvivorship NAPBC Lead your Breast Program to Excellence conference, Chicago, IL. Presented by: Jorge Nieva, MD, Chair of Hematology and Oncology

Regional Presentations• Breast cancer in Wyoming 2013

Powell Valley Healthcare providers, Powell, WY Presented by: Robert Joseph, MD, Cody Oncology

• Cancer survivorship Billings Clinic Primary Care Fall Workshop, Billings, MT Presented by: Jorge Nieva, MD, Chair of Hematology and Oncology

• Cancer survivorship Oncology for Primary Care Physicians Conference, Kalispell, MT Presented by: Justine DeRousse, PA-C, Cody Oncology

• Cervical cancer: Screening, prevention and treatment Billings Clinic Women’s Health Symposium, Billings, MT Presented by: Erin Stevens, MD, Gynecologic Oncology

• Communication techniques with palliative and end-of-life care End-of-Life Nursing Education Consortium (ELNEC), Billings, MT Presented by: Jennifer Finn, LCSW, OSW-C, Cancer Programs


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• Cultural differences with end-of-life care End-of-Life Nursing Education Consortium (ELNEC), Billings, MT Presented by: Shawna Cooper, Oncology Patient Advocate

• Cultural sensitivity and reflections on hope and cancer Big Sky Oncology Nursing Society Conference, Billings, MT Presented by: Meg Hatch, MDiv, Pastoral Care

• End-of-life care End-of-Life Nursing Education Consortium (ELNEC), Billings, MT Presented by: Jeannine Brant, PhD, APRN, AOCN®, Nurse Scientist and Oncology Clinical Nurse Specialist

• Enteral tubes: What, where, how Big Sky Oncology Nursing Society Conference, Billings, MT Presented by: Beth Hall, RD, CLC, CSO, LN, Oncology Dietitian

• Ethical and legal challenges in palliative care End-of-Life Nursing Education Consortium (ELNEC), Billings, MT Presented by: Erin Stevens, MD, Gynecologic Oncology

• Grief, loss, and bereavement End-of-Life Nursing Education Consortium (ELNEC), Billings, MT Presented by: Meg Hatch, MDiv, Pastoral Care

• New drug therapies for metastatic prostate cancer Big Sky Urology Conference, Big Sky, MT Presented by: Ala’a Muslimani, MD, Hematology and Oncology

• Nurse navigators’ role in cancer survivorship Big Sky Oncology Nursing Society Conference, Billings, MT Presented by: Karyl Blaseg, RN, MSN, OCN®, Manager of Cancer Programs

• Pain management in palliative care End-of-Life Nursing Education Consortium (ELNEC), Billings, MT Presented by: Jeannine Brant, PhD, APRN, AOCN®, Nurse Scientist and Oncology Clinical Nurse Specialist

• Palliative care and end-of-life care Big Sky Oncology Nursing Society Conference, Billings, MT Presented by: Jennifer Finn, MSW, OSW-C, Oncology Social Worker

• Pediatric oncology Billings Clinic Primary Care Fall Workshop, Billings, MT Presented by: Courtney Lyle, MD, MAS, Pediatric Oncology

• Pediatric end-of-life care Hot Topics in Pediatric Nursing, Billings, MT Presented by: Courtney Lyle, MD, MAS, Pediatric Oncology

• The science of clinical trials Montana Cancer Control Consortium annual meeting, Bozeman, MT Presented by: Jorge Nieva, MD, Chair of Hematology and Oncology

• Scientific basis of targeted therapeutics Big Sky Oncology Nursing Society Conference, Billings, MT Presented by: Pam Smith, MD, Hematology and Oncology

• Symptom management at end-of-life End-of-Life Nursing Education Consortium (ELNEC), Billings, MT Presented by: Kathryn Waitman, DNP, AOCNP®, Hematology and Oncology; Alison Weber, RN, BSN, Cancer Programs; Jennifer Finn, LCSW, OSW-C, Cancer Programs; Linda Shelton, PT, Cancer Programs

• Treatment of bone metastasis in prostate cancer Big Sky Urology Conference, Big Sky, MT Presented by: Ala’a Muslimani, MD, Hematology and Oncology

• Treatment modalities: Surgery, transplant, radiation therapy, chemotherapy, targeted therapy, and biotherapy Big Sky Oncology Nursing Society Conference, Billings, MT Presented by: Venu Thirukonda, MD, Hematology and Oncology

• When to refer to a Gynecologic Oncologist Billings Clinic Primary Care Fall Workshop, Billings, MT Presented by: Erin Stevens, MD, Gynecologic Oncology


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Billings Clinic Grand Rounds Presentations• Anemia

Presented by: Ala’a Muslimani, MD, Hematology and Oncology• Collaborative management of breast cancer

Presented by: Simone Davion, MD, Pathology; Ala’a Muslimani, MD, Hematology and Oncology; Michelle Proper, MD, Radiation Oncology

• Myths versus realities: Gynecologic cancers Presented by: Erin Stevens, MD, Gynecologic Oncology


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