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
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
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
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
Estimated Performance Rates (%)
Image or palpation-guided needle biopsy (core or FNA) of the primary site
is performed to establish diagnosis of breast cancer
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
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
Radiation is administered within 1 year of diagnosis for women under the
age of 70 receiving breast conservation surgery for breast cancer
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
CP3R Colon Measures
Estimated Performance Rates (%)
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
At least 12 regional lymph nodes are removed and pathologically examined
for resected colon cancer
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
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
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.