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Cancer Center

Cancer Center Annual Report

2015 Annual Report


Whole Health Approach to Cancer Care

The Cancer Center 2015 Annual Report focuses on screening cancer patients for support services so that they may navigate treatment with the least amount of disruption and achieve a more successful recovery. Referral services include nutrition, palliative care, rehabilitation and more.

Learn about:

  • Distress screening and how it is improving cancer treatment.
  • What referral services patients utilized and how they reduced cancer recurrence, lowered depression
    and decreased additional healthcare utilization.
  • Select performance rates for breast and colon cancer.

Click here for full report.

Older Cancer Center Annual Reports

2014 Annual Report

2014 Annual Report

Incidence, Care and Treatment of Urologic Cancers at Bozeman Health

A diagnosis of cancer is always unsettling, but in the Gallatin Valley, there’s good news for many patients diagnosed with a urologic cancer. The majority of prostate, bladder, and kidney cancer cases diagnosed and/or receiving first course treatment at Bozeman Health Cancer Center are diagnosed at an early stage. This is important because early stage cancers are diagnosed prior to regional or distant spread, thus increasing disease free intervals and overall survival.

In fact, nationally, more than 95% of patients diagnosed with prostate, bladder or kidney cancer at Stage Two or lower survive the illness. And these patients made up more than 80% of the patients treated at Bozeman Health Cancer Center between 2010 and 2013 (most recent data available)

Of 251 prostate cancer cases diagnosed at Bozeman Health within the time frame listed, 113 were found in Stage I and 94 in Stage II, while only 44 were diagnosed in Stage III or IV. For 74 patients with bladder cancer, 61 cases were diagnosed in Stages 0a, 0is, I or II, and only 13 were found in Stage III or IV. Finally, among 48 kidney cancer cases, 31 were diagnosed in Stages I and II and 17 were diagnosed in Stages II and IV.

Another positive indicator for patients with prostate cancer was their low PSA (prostate-specific antigen) value at time of diagnosis. Less than two dozen patients had normal values when diagnosed with the disease, and more than 140 of the 251 patients had a PSA value in the 4-10 range. In fact, about 85% of all prostate cancer patients diagnosed in Stage I or II had PSA values in the 4-10 range at time of diagnosis. About 40 patients were in the 10-20 range and only 30 had PSA values greater than 30.


Bladder Cancer and Tobacco Use

Use of Mitomycin C in Non-Muscle Invasive Bladder Cancer

By J. Bruce Robertson, MD, Bozeman Health Urology

As part of continuous quality improvement at Bozeman Health Cancer Center, we recently reviewed the use of a single dose of Mitomycin C (MMC) as additional therapy immediately following surgery for transurethral resection (TURBT) of low stage transitional cell carcinoma of the bladder.

Bladder cancer is the seventh most common soft tissue malignancy in men and 17th most common in women in the U.S., with an estimated 65,000 to 75,000 new cases each year. The cost of treatment in the U.S. in 2012 was approximately $3.98 billion.

American Urological Association guidelines published in 2007 and current NCCN guidelines recommend including administration of a single peri-operative (during surgery) dose of MMC following TURBT for non-muscle invasive bladder cancer (NMIBC).

To assess our adherence to published guidelines and best practices in the treatment of NMIBC, we reviewed all TURBTs performed at Bozeman Health Deaconess Hospital from January, 2013, through September, 2015, to determine what percentage of eligible patients actually received the recommended dose of MMC following TURBT.

Of the 76 patients within the timeframe, 71 were eligible to receive MMC. Three were ineligible due to suspected bladder perforation during TURBT, one because muscle-invasive bladder cancer was apparent during the procedure and one due to a prior poor response to a full course of Mitomycin C. Of the 71 patients who were candidates for peri-operative MMC, 46 (65%) received the recommended dose and 25 (35%) did not.

Adequate data supports the use of a single, peri-operative dose of MMC following TURBT in an effort to reduce the risk of recurrent tumors. With regard to our experience at Bozeman Health, with peri-operative administration of MMC for NMIBC, we feel that there is room for improvement. Unfortunately, our data do not reveal a reason or reasons for the lack of use of MMC in 35% of our patients. It is, therefore, somewhat difficult to identify specific performance improvement initiatives such as re-education, distribution of guidelines, etc. that might have an impact. To our knowledge there is no published benchmark regarding the percentage of eligible patients who should receive MMC after TURBT.

For the future, we therefore selected a somewhat arbitrary goal of increasing our use of MMC following TURBT to 90% for eligible patients. To this end we modified our pre-operative TURBT order set to include a section requiring the surgeon to specifically accept or decline MMC and specify a reason if MMC is declined. In addition, in 2016 we will add a specific question regarding Mitomycin C to our pre-operative time out procedure for TURBT. We plan to review the data in 2016 to assess the impact of these changes.

By Audrey Baker, CTR, Cancer Registrar, Bozeman Health Cancer Center

Most people associate smoking with significantly increasing your risk for lung cancer, but tobacco use also can lead to bladder cancer. The adjacent graph is a depiction of the strong correlation between bladder cancer and current and former tobacco use, as reported in the Bozeman Health Cancer Registry.

According to an article published in 2011 by the National Institutes of Health reflecting new research, current cigarette smokers have a higher risk of bladder cancer than previously reported. The study also found that the proportion of bladder cancer due to smoking in women is now the same as for men-about 50%. The article also reported that former smokers were twice as likely to develop bladder cancer as those who never smoked, and current smokers were four times more likely.

As shown in the graphic, 73% of patients in the Bozeman Health Cancer Registry diagnosed with bladder cancer between 2010 and 2013 reported either current or former tobacco use. Of 75 cases at Bozeman Health Cancer Center, 35 patients were former tobacco users and 19 still smoked cigarettes, cigars or pipes or used smokeless tobacco. Only 21 patients reported no tobacco use at all.


Meeting ACoS Standards

The American College of Surgeons- the professional organization that accredits Bozeman Health Cancer Center-requires that all accredited facilities meet particular standards every year. Here is how Bozeman Health Cancer Center met some of these standards in 2014, all designed to fulfill community needs:

Standard 4.1 - Prevention Programs

Each year, the Cancer Center provides at least one cancer prevention program designed to reduce the incidence of a specific cancer type. For 2014, the cancer selected was lung cancer and the need identified was for a low dose screening program for lung cancer. At the 2014 Bozeman Health Community Health Fair, held in the spring, vouchers for low dose screenings were made available, and four community members participated.

Standard 4.2 - Screening Programs

Each year, the Cancer Center provides at least one cancer screening program targeted to decrease the number of patients with late-stage disease. The need identified was for lung cancer screening. Vouchers for low dose lung cancer screenings were made available at the 2014 Bozeman Health Community Screening Day, and four community members participated.

Standard 4.6 - Monitoring Compliance with Evidence-Based Guidelines

Each year, a Cancer Center physician performs a study to assess whether patients in a specific program are evaluated and treated according to evidence-based national treatment guidelines. For 2014, Kenneth May, MD, PhD, considered the use of cisplatin-based chemotherapy before cancer surgery for all Cancer Center patients with muscle-invasive bladder cancer in Stages T2-T4, as is strongly recommended by National Comprehensive Cancer Network (NCCN) guidelines. All nine Cancer Center patients with muscle-invasive bladder cancer in Stages T2-T4 were considered for the cisplatin-based chemotherapy. Four eligible patients received the recommended chemotherapy before surgery, three declined chemotherapy treatment, one patient was not eligible for chemotherapy and one ultimately was not eligible for cancer surgery.

Standard 4.7 - Studies of Quality

Each year, based on various categories, the quality improvement coordinator develops, analyzes and documents required studies that measure quality of care and outcomes for patients. In 2014, issues analyzed involved allergies and full bladders:

An opportunity for improvement was identified with the process of assessing and documenting allergies in outside infusion patients, from the initial infusion order through the patient receiving infusion services. The Cancer Center began implementing allergy assessments on all outside infusion patients and added daily reminders in nursing huddles about this issue. This resulted in a drop from one medication error and three Great Catches (in which imminent errors were caught before they were made) in 2012-13 to zero medication errors and one Great Catch during the course of the study.

Cancer Center staff also sought to improve the Radiation Oncology “full bladder simulation” process as time delays were causing overly full bladders in some patients. As delays can occur during the registration process in Radiology, Radiation Oncology staff now registers these patients before sending them to Radiology to expedite the process.

Stand 4.8 - Quality Improvements

The quality improvement coordinator implements two patient care improvements annually. One improvement is based on results of a study that measures quality of can and outcomes while the other can be from another source or another completed study.

In 2014, three staff members were trained as Certified Application Counselors to help uninsured patients navigate the process to obtain insurance through the Healthcare Exchange. Another quality improvement in patient care came about through the expansion and renovation of the Radiation Oncology department, which now includes a new vault/linear accelerator with SRBT capabilities, gender-segregated dressing and waiting areas and a handicap-accessible dressing room. A third improvement resulted from the study regarding outside infusion patient allergies, with the resulting improved process for checking outside infusion patients’ allergy lists.


American College of Surgeons CoC Accreditation

Bozeman Health Cancer Center is accredited by the American College of Surgeons (ACoS) Commission on Cancer (CoC). CoC accreditation means that the Cancer Center adheres to strict standards set to ensure that high quality cancer care is provided. Bozeman Health Cancer Center has been accredited through the CoC since 2009, and has been through two subsequent re-accreditation surveys in 2012 and 2015.

ACoS also requires regular review of certain accountability and quality measures. These measures are included in the CoC’s CP3R (Cancer Program Practice Profile Reports).

Bozeman Health performs above recommended thresholds in all measured activities, consistently exceeding the required standards. Please see the following list of quality measures and Bozeman Health’s reported performance related to each.

CP3R Breast Measures

Select Measures

Performance Standard

CoC Standard

Estimated Performance Rates (%)

2011

2012

2013

Image or palpation-guided needle biopsy (core or FNA) of the primary site is performed to establish diagnosis of breast cancer

Quality Improvement

80%

84.2

88.9

91.5

Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year of diagnosis for women with AJCC T1c or stage IB-III hormone receptor positive breast cancer

Accountability

90%

93.3

100

96.6

Radiation therapy is considered or administered following any mastectomy within 1 year of diagnosis of breast cancer for women with >=4 positive regional lymph nodes

Accountability

90%

100

No data

No data

Radiation is administered within 1 year of diagnosis for women under the age of 70 receiving breast conservation surgery for breast cancer

Accountability

90%

93.1

100

100

Combination chemotherapy is considered or administered within 4 months of diagnosis for women under age 70 with AJCC T1cNO, or stage IB-III hormone receptor negative breast cancer

Accountability

90%

100

100

100

CP3R Colon Measures

Select Measures

Performance Standard

CoC Standard

Estimated Performance Rates (%)

2012

2013

Adjuvant chemotherapy is considered or administered within 4 months of diagnosis for patients under the age of 80 with AJCC stage III (lymph node positive) colon cancer

Accountability

90%

100

100

At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer

Quality Improvement

85%

100

90.0


Cancer Registry

By Audrey Baker, CTR, Cancer Registrar, Bozeman Health Cancer Center

The Bozeman Health Cancer Registry collects thorough and high quality data on all reportable cases of cancer seen at Bozeman Health. Information collected includes demographics, diagnostic findings, staging, prognostic factors, treatment types, and life-long follow up of patients.

The registry is staffed by skilled professionals who currently hold or are working towards the industry-recognized credential, CTR (Certified Tumor Registrar). In accordance with American College of Surgeons, Commission on Cancer (ACoS CoC) Standards related to high quality data collection, all registry staff members participate in regular educational cancer registry activities approved by the National Cancer Registrars Association.

Bozeman Health’s Cancer Registry reports cancer data to the Montana Central Tumor Registry as required by law. As an ACoS accredited facility, Bozeman Health also submits statistical data to the National Cancer Database, and is included in national statistics for incidence reporting and cancer research. Since its establishment in 1980, Bozeman Health Cancer Registry has collected 11,663 cases of reportable cancer.

Confidentiality of patient identifying information and related medical data is strictly maintained at Bozeman Health. Aggregate data are analyzed and published without any patient identifying information.

The Cancer Registry Department at Bozeman Health participates in additional professional activities as part of the health care leadership team. The staff facilitates Cancer Conference, a weekly multidisciplinary forum for discussion of current cancer cases that promotes a collaborative approach to patient care. Staff actively participate in Cancer Committee , the body responsible for cancer program leadership that also ensures Bozeman Health adheres to the highest standards in cancer care as outlined by the ACoS.

For additional information about the Cancer Registry, contact the registry office at Bozeman Health at 406-414-5085.


Image-Guided Cryoablation for Kidney Cancers: A Minimally Invasive Treatment Option

By R. Taylor Handley, MD, Intercity Radiology

Renal cell carcinoma (RCC, also known as kidney cancer) is quite common, with 50,000 new cases diagnosed each year in the U.S. Incidence of RCC is on the rise, but this may be credited to the increased use of medical imaging, especially CT and MR scans. Such scans can lead to RCC often being found “accidentally”, as the ordering doctor was looking for something else.

In the past, the only treatment option for RCC was surgical removal of the entire kidney (nephrectomy) by a urologist, no matter how large or small the tumor. Eventually, for smaller tumors, urologists (specialist physicians of the kidneys/bladder) began performing a less invasive surgery which only removes the tumor and spares the rest of the kidney, called partial nephrectomy.

Over the past 10-15 years, minimally invasive treatment options have been developed for treatment of small RCCs. In these treatments, known as ablations, imaging guidance (ultrasound or CT) is used to precisely place a single or multiple needles through the skin in the back, and into the tumor. Then energy is passed through the needle in order to destroy the tumor, leaving the normal surrounding kidney tissue intact.

The two main types of minimally invasive ablation are: 1) Cryoablation, in which freezing of the tumor tissue results in cell death; and 2) Radiofrequency Ablation (RFA), in which heat energy results in tumor destruction. Both techniques have been extensively studied and have about equivalent results. At Bozeman Health Deaconess Hospital, we mainly use cryoablation.

CT-guided cryoablation is performed by an Interventional Radiologist (a specialist who does image-guided/minimally invasive therapies), sometimes in conjunction with a urologist. The patient is sedated for the procedure using IV medications, and general anesthesia is rarely required. The procedure is almost always performed as an outpatient procedure, with patients going home the same day of the procedure.

Initially, ablation therapies for RCC were offered only if the patient was not a surgical candidate, due to other medical conditions that made the procedure too risky, or sometimes due to patient preference. Numerous medical studies published over the past 10-15 years, now prove that ablation therapies are excellent options for small RCCs, with nearly equivalent results. In fact, a retrospective study comparing ablation to partial nephrectomy showed no significant difference in patient survival or tumor recurrence at five years. Compared to surgery, cryoablation results in fewer immediate complications, is often cheaper, and requires shorter hospital stays (usually none).

However, CT-guided cryoablation is not an option for all patients with RCC, and typically is used only for smaller tumors. Results have been best when treating tumors 4 cm or smaller (Stage T1a disease). It is important that a urologist evaluate any patient diagnosed with RCC and direct the treatment plan, referring patients for minimally-invasive therapies such as cryoablation only if appropriate.

Interventional radiologists Taylor Handley, MD, and Sean Kalagher, MD, perform image-guided cryoablation for RCC here at Bozeman Health Deaconess Hospital, and have an excellent working relationship with Bozeman Health Urology.

Above: CT scan showing a small tumor (red arrows) arising from the back of the kidney (“K”)

Above: CT scan during the cryoablation procedure, showing the cryotherapy needle (bright white line / red arrows) in the tumor, with a round grey zone surrounding the needle tip (blue arrows) representing the “ice ball” which will destroy the tumor.


Pelvic Rehabilitation for Incontinence and Pain Related to Cancer

By Martha Stoner PT, DPT, Bozeman Health Rehabilitation

Pelvic rehabilitation is physical therapy that focuses on the evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunction can be caused by many different diseases or conditions, some benign and others more serious. Typical symptoms include urinary or fecal incontinence or leakage, elimination frequency during the day or night, hesitancy, pain with urination, constipation or incomplete elimination, pain with sexual intercourse or generalized pelvic pain. Certain cancers and cancer treatments can cause or exacerbate pelvic floor dysfunctions or symptoms.

A physical therapist trained to evaluate and treat pelvic floor issues can help a patient improve their quality of life, overall function, and emotional wellbeing. A diagnosis of cancer does not limit a person’s ability to participate in physical therapy, unless dictated by their physician. In fact, physical therapy is non-invasive and beneficial in most aspects of a patient’s life, as illustrated by the STAR program (Survivorship Training and Rehabilitation, a nationally recognized cancer survivorship program). Pelvic rehab to address incontinence and/or pain generally can begin after medical treatments are completed, and have been shown to have positive results.

Located at the base of our pelvic bones and made up of layers of muscles, the pelvic floor is a vital part of our bodies. It acts in conjunction with our bladder and rectum for sphincter control, aids in sexual function, gives secondary support for pelvic organs, assists with core stabilization, and assists with our lymphatic system. The pelvic floor muscles are small but play an important role in our daily lives. When they are not working properly, significant problems can arise.

Incontinence can be the result of muscle weakness or poor muscle endurance, or even overworked muscles that are in pain. However, it also can be the initial symptom of something more serious, especially if accompanied by pain with urination, hesitancy with starting or continuing urination, or pelvic, abdominal, or flank pain. The pelvic floor muscles also can be the actual source of pain, but regardless the cause or location of pain, it can be debilitating and is a cause for concern.

Physical therapy treatments for the pelvic floor are based on evaluations of each patient’s needs and can include therapeutic exercise, neuromuscular re-education, manual therapy techniques, biofeedback training and patient education. For incontinence, treatment focuses on exercises and neuromuscular re-education that emphasizes improving strength, endurance and coordination of those muscles so they function appropriately, with correct timing, and in coordination with complimentary muscle groups.

Education is another key component, addressing body mechanics and postures to improve bladder health and understanding of irritants to the system, and re-educating the bladder through urge suppression training. For pelvic pain, the focus is directed toward reducing muscular or myofascial restrictions and improving muscle activation and relaxation through manual therapy techniques and neuromuscular re-education.

Cancer treatments such as chemotherapy, radiation therapy and surgery can cause a myriad of problems to the pelvic area, including bowel and bladder dysfunction, sexual dysfunction, infertility, skin issues, scarring and adhesions, pain, lymphedema, and generalized muscle fatigue, weakness, and deconditioning. Urological cancers can lead to various bladder related issues, but physical therapy may still be able to improve leakage or retention with re-training the pelvic floor muscles. Prostate cancer and treatment can have a huge impact pelvic function. For prostate cancer and treatment, many studies suggest that post-surgical pelvic floor muscle re-training can be beneficial in reducing the length of time of incontinence, thereby improving quality of life and overall function.


2013 Annual Report

2013 Cancer Center Annual Report

Our 2013 Annual report takes a look at skin cancer screening and treatment. This report also features a touching survivor story to help current patients.

Click Here to view the Cancer Center 2013 Annual Report.

2012 Annual Report

2012 Cancer Center Annual Report

Our 2012 Annual report takes a look at treatment of Breast Cancer and takes a deep dive into the advancements in 3D Mammography. The report also discusses risk factors and best practices for screenings and treatment.

Click Here to view the Cancer Center 2012 Annual Report.

2011 Annual Report

2011 Cancer Center Annual Report

Our 2011 report features a special focus on head and neck cancer. Our otolaryngologist and speech-language pathologists have contributed to this years report to provide a comprehensive look at the specific challenges, research, treatments, as well as information and services surrounding head and neck cancer.
Click Here to view the Cancer Center Annual Report.