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2012 Cancer Annual Report

Breast Cancer Treatment Experience at Fremont Area Medical Center
2012 Cancer Annual Report

According to data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI), breast, lung, and colorectal tumors are the three most common malignancies in women with breast cancer accounting for 31% of all new cancer cases. In real numbers this translates into approximately 226,870 new cases of breast cancer in 2012, with 39,510 cancer related deaths. The SEER data also reveals that the breast cancer incidence increased by 3.8% per year between 1980 and 1987. Since that time, the rate of increase of the incidence of breast cancer slowed significantly.

The latest mortality data available from the National Center of Health Statistics, fortunately, reveals some encouraging trends as well. Breast cancer death rates began to decline in 1990. From 2005 to 2009, women under 50 experienced a 3.1% annual decline in mortality rate, while those over 50 had a 2% decrease. Earlier detection and improved treatments are responsible for these declining rates.

From 2003 to 2009, there were 386 breast cancer patients treated at Fremont Area Medical Center. It represents the most common malignancy in women, followed by colorectal and lung, in decreasing order of frequency.

The average breast cancer patient is slightly older than the typical patient treated for this disease in the U.S. The age distribution of these patients revealed a peak occurrence in the 70 to 79 age group, followed closely by the 60 to 69 group. In the state of Nebraska, the age group with the highest peak incidence is the 50 to 59 range, with lesser peaks in the following decades.

    Age Distribution   

    FAMC   

    National   

30-39 3% 5%
40-49 13% 19%
50-59 18% 25%
60-69 27% 23%
70-79 24% 18%
80+ 16% 10%

Many of these patients have other co-existing diseases that make cancer treatment more difficult. The Charlson Comorbidity Index evaluates patients based on the absence or presence of other disease. A score of 0 indicates none exist for those patients, while the numbers 1 and 2 would indicate groups of patients with increasing numbers of other diseases such as hypertension, heart disease, and diabetes mellitus. Compared to national data, this table indicates that the breast cancer patients treated through this facility have more complicated medical conditions.

    Co-morbidity Score     

     0    

     1    

   2 or >  

    N/A    

FAMC 52% 14% 3% 32%
National 61% 8% 2% 30%

In spite of these challenges, some excellent results for breast cancer patients have been achieved at Fremont Area Medical Center.

Reducing Mortality

To improve outcomes and reduce the mortality from breast cancer, Fremont Area Medical Center has made significant progress regarding earlier diagnosis and providing treatment that is consistent with nationally recognized standards.

 

Breast Cancer Study, 2011

Early Diagnosis - Screening Mammography

The purpose of screening mammography is to discover existing disease at an earlier and more curable stage. The Breast Cancer Surveillance Consortium at the NCI has developed and continuously monitors a series of benchmarks for mammography screening programs. These benchmark results are for quality determinants of screening mammography that can be used to determine its effectiveness in finding disease at an early and more curable stage. They are:

  1. Percentages of tumors found by screening that are stage 0 or 1 (73%)
  2. Invasive tumors found through screening with negative lymph nodes  (76%)
  3. Tumors found that are defined as minimal cancer < 1cm or DCIS (53%)

Scope of study: Since the purpose of the study is to evaluate the effectiveness of the screening mammography service provided at Fremont Area Medical Center, analytic class 0 and 1 breast cancer cases from 2009 and 2010 were evaluated.

Data: During this period of time, there were 55 analytic class 0 and 1 breast cancer cases at FAMC. 32 of these cancers were discovered by screening mammography. The others were discovered with other imaging techniques or biopsy of a palpable mass.

Criteria

FAMC

Benchmark

Stage 0 and 1

   78% (25/32)  

73%

Lymph node negative

90% (18/20)

76%

Minimal cancer

47% (15/32)

53%

Discussion of results: For each of the quality measures, the screening mammography service at Fremont Area Medical Center performed at a level that is above the recommended rate.

In 2009, there were 13 breast cancer cases discovered by screening mammography and 5 of them were classified as minimal cancer (38.5%). In 2010, there were 19 breast cancers discovered through mammography screening and 10 were classified as minimal (53%). These figures demonstrate an improving trend.

There were 22 patients discovered to have an invasive carcinoma by screening mammography, but 2 of them did not have any pathologic lymph node assessment that could be found. One of these patients was very elderly and had only a lumpectomy. The lymph nodes were clinically negative. Including each of these 2 patients produced a negative lymph node rate of 82%, which is still above the benchmark rate of 76%.

Conclusion: Using the benchmark rates for the quality determinants provided by the Breast Cancer Surveillance Consortium, the screening mammography service at the Fremont Area Medical Center is very effective and discovers breast cancer in an early more curable stage.

 

Treatment

Treatment improvements are the second reason for the declining mortality rate of breast cancer patients. These improvements include the development of more effective treatment regimens that incorporate the utilization of radiation therapy, chemotherapy, and hormonal therapy.

Comprehensive treatment planning for breast cancer patients is provided by a team of cancer specialists that meets weekly to develop a specific treatment plan for each patient based upon their needs and the extent of the disease. This collaborative approach to breast cancer treatment assures each patient that their treatment plan is based upon nationally recognized standards and is delivered in a timely manner to achieve the best possible outcome.

 

Breast Conserving Therapy and Radiation

Patients who are considering lumpectomy visit with the radiation oncologist to discuss the purpose of the treatment and possible side effects. These pretreatment consultations provide patients with a better understanding of the importance of combining radiation with lumpectomy to achieve better outcomes. At Fremont Area Medical Center, this educational process has enabled patients who selected breast conserving therapy to achieve a high level of adherence to the treatment standard that requires radiation therapy be combined with lumpectomy.

 

Chemotherapy and Hormonal Therapy

Other important treatment modalities for the management of breast cancer are adjuvant chemotherapy and hormonal therapy. These treatments reduce the risk of developing metastatic disease which adversely impacts survival rates. 

At Fremont Area Medical Center, the merits of adjuvant chemotherapy are considered for each case. Recent clinical studies have verified that adjuvant combination chemotherapy provides a significant survival advantage to patients with breast cancer, especially if the primary tumor is greater than 1 cm in diameter. This fact would indicate that some patients with stage 1 disease, most patients with stage 2, and all of stage 3 breast cancer patients would benefit from adjuvant chemotherapy as part of the first course of treatment.

For patients with hormone receptor positive tumors there is ample clinical evidence of the benefit for including Tamoxifen or an aromatase inhibitor in the treatment plan. Through the patient evaluation process each case is considered on an individual basis, and a treatment plan is developed that includes hormone therapy if it is in the best interest of the patient to assure a good outcome.

 

Quality Measures

The cancer program at Fremont Area Medical Center uses information technology and comparative data bases to continuously evaluate, analyze, and improve the quality of care provided to breast cancer patients at this facility. Reliable reporting tools have been developed to make certain that breast cancer treatment plans adhere to nationally recognized standards and the plan is completed in a timely manner in order to achieve the best possible outcome for each individual. These quality measures are important steps in a treatment process that are proven to have a positive effect on the outcome of the patient.

The quality measures for breast cancer include:

  • Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer
  • Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under 70 with AJCC T1c, or Stage II or III hormone receptor negative breast cancer
  • Tamoxifen or third generation aromatase inhibitor is considered or administered within one year (365 days) of diagnosis for women with AJCC T1c or Stage II or III hormone receptor positive breast cancer
 
Outcomes

These web based electronic reporting tools also provide aggregate data that permits comparison studies with other hospitals in Nebraska and also nationally. These results indicate that each breast cancer patient has a treatment plan that is based on nationally recognized guidelines and has been completed in a timely manner to provide them with an opportunity for the best possible outcome. The high rates of adherence to these quality measures for breast cancer patients treated through Fremont Area Medical Center exceeds the rates achieved in other hospitals at the state, regional, or national levels. These outstanding results can assure breast cancer patients that they are receiving high quality care close to home. These results are displayed in the following charts. 

Select Breast Cancer Measures

Estimated Performance Rates

2004

2005

2006

2007

2008 

2009 

Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. [BCS/RT]

100% 100% 93.8% 100% 100% 100%

Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c N0 M0, or Stage II or III ERA and PRA negative breast cancer. [MAC]

100% n/a 100% 100% 100% 100%

Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c N0 M0, or Stage II or III ERA and/or PRA positive breast cancer. [HT]

83.3% 100% 100% 100% 100% 100%

 

Conclusion

These studies indicate women have access to very effective screening mammography services at the Fremont Area Medical Center, so that breast cancers can be diagnosed at any earlier, and  more curable stage. For those who are diagnosed with breast cancer, treatment plans are provided that are concordant with nationally recognized guidelines. Both of these cancer related activities are necessary for reducing the mortality from this disease process.