Cancer Annual Report 1993

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James R. Barton, M.D., Otolaryngology Gerardo A. Caballero, M.D., Surgery David Czarnecki, M.D., Radiology AileenE. Denny, M.D., Medical Oncology William Deshur, M.D., Surgery Ajit Divgi, M.D., Medical Oncology John P. Hanson, Jr., M.D., Medical Oncology Ronald D. Hart, M.D., Medical Oncology Stephen R. Hazelrigg, M.D., Thoracic Surgery Jonathan Kay, M.D., Anesthesiology Elmer Lehman, M.D., Obstetrics & Gynecology ‘ Howard J.Lewis,M.D., Radiation Oncology John R. Linscott, M.D., Family Practice Mary E. Ness, M.D., PhysicalMedicine & Rehabilitation Samuel Otto, M.D., Urology WilliamJ.Pao, M.D., Radiation Oncology Jorge Pellegrini,M.D., Pathology Nancy B. Petro, M.D., Surgery Marcia J.S. Richards, M.D., Chairperson, Radiation Oncology Paul Sienkiewicz,M.D., Orthopedics Elaine M. Thomas, M.D., Pediatrics Marija Bjegovich,RN, Supervisor,Vince Lombardi Cancer Clinic Sandy Blixt, RRA, Cancer Registry Coordinator, Medical Records Judy Eager, RN, OCN, Cancer Education Coordinator Mike Farina, Pharmacist Vicki George, VicePresident SheriHackbarth, RRA, Cancer Registrar, Medical Records Frank Kalivoda, VicePresident Angela Klimaszewski,Cancer Research Coordinator Vicki Koceja, RN, Patient Care Manager, 8GHJK Marcia Marino, Chaplaincy Services Grace McCutcheon, SocialServices Karen Nilles, Quality Management Nancy Nowak, Director, Cancer Program Mary M. Schmidt, RN, CNS, Oncology Kathy Schroeder, RN, Autologous Bone Marrow Transplant Kerry Twite, RN, CNS, Oncology Nancy Vogt, ART, CCS, Supervisor,Medical Records Phil Whitton, Manager, Radiation Oncology Joanne Ziarek, Pharmacy

MED.CTR. :F;;A:JBRAPY TABLEOFCONTENTS

Introduction for Annual Report 1993 1

ScreeningMammography for Pre-Menopausal Women 2

Genetic and Environmental Factors Predisposing Breast Cancer 4

Stereotactic Breast Biopsy 5

Pathologic Factors and Prognostic Indicators in Breast Cancer 6

SurgicalOptions for Breast Cancer 8

ExercisePost Mastectomy i 9

Reconstruction/Plastic SurgeryFollowing Breast Surgery 10

The Role of Radiation Therapy for Breast Cancer 12

SystemicTherapy for Breast Cancer 14

Vince Lombardi Cancer ClinicUpdate 17

Autologous Bone Marrow Reinfusion 18

Autologous Bone Marrow Transplant Program Analysis 19

The Cancer Program Team 20

Public Breast Cancer Awareness Program Featuring Susan Ford Bales 21

Support - A Time for Sharing 22

Support Groups Offered at St. Luke’sMedical Center 23

1993 StatisticalSummary 24

Cancer Conferences 30

Community Education 32

Glossary 33

References 34 INTRODUCTIONFORANNUALREPORT1993

New programs, new people, new projects - the story of the CancerCommittee in 1993 at St. Luke’sMedical Center. In addition, other activitieswereguided in part by the followingpriority goalsfor the year. The goalswerechosenby the committeeand overseenthrough the year by one physicianand one program staffmember. Effortswere begunin all areas,howeverreportable accomplishmentswillnot be achieveduntil next year. Cancer Committee Goals for 1993-1994 . Monitor and react to health care reform as it relates to cancer service . Collaborate with other hospital programs includingWomen’s and Men’sHealth Marcia J.S. . Developstrategiesto involveprimarycare physiciansin the Richards, M.D. cancerprogram . service plan for all oncologydepartments Developa management A Chairperson of . Developcomprehensive,qualitydiseasesiteprogramsin a Cancer Committee cost effectivemanner

There were many programmatichighlightsthis year. The 1st Surgical OncologyConferencewas coordinated by the energeticsurgicaloncology subcommitteefeaturingfour internationallyknown speakersaddressing diversetopics. Radiologysaw the openingof a new BreastImagingCenter, includingthe use of stereotaxicneedlebiopsyin the new outpatient facility. Under the guidanceof the RehabilitationMedicineDepartment,a program for oncologicrehabilitationwas initiatedwhichwas aimedat outpatients. For the firsttime Tumor Conferencescontinued for the summer,with a new format of co-moderators. Intensework was also begunon developinga coordinated program for the care of patients with breast cancerwith departmentalstan- dards developedby each involveddepartment and/or section.

Ongoingquality assuranceactivitieswith the AmericanCollegeof Surgeons includedlong and short term reviewstudiesof patientswith cervicaland prostate cancer. Additionally,institutionalstudieswere done evaluatingthe oncologyBeta-indicatorstudy for the Joint Commissionon Accreditationof Healthcare Organizations(JCAHO),and a studylookingat the correlationof CT directedneedlebiopsiesof the lungwith open biopsiesfor patientswith undifferentiatedmalignancies.

Activitiesthrough the VinceLombardi Cancer Clinic(and supportedby the generouseffortsof the Lombardi Classicand Ball)includedoutreachlectures on oncologictopics givenby our staffand visitingspeakers. Highlights included“SurvivorshipIssues”discussedby SusanLeighfrom the National Coalitionfor Cancer Survivorsand SusanFord addressingher experiencewith her mother’sbreast cancerto a largeaudienceat the Italian Community Center. Other communityeffortsincludedco-sponsorshipwith the American Cancer Societyof the Bike-a-thonand a 24 Hour Relay. Lombardieffortsalso continuedto support a number of institutionalresearchprojects.

Ann LeFever,Ph.D., was added as a researchscientistin the immunotherapy and bone marrow program and Marcia Marino started as the CancerCenter chaplain. We also saw the departure of Nancy Nowak as ProgramDirectorto warmer environs.

Another year welldone by all membersof the cancercommitteeand the entire oncologyprogram.

Marcia J.S. Richards,M.D. Chair of Cancer Committee

1 SCREENNGMAMMOGRAPHYFORPRE-MENOPAUSAL WOMEN:AMEDICALCONTROVERSY

Accordingto the AmericanCancerSociety,there will be 3,800 new casesof breast cancer in the state of Wisconsinin 1994. Althoughmost of these patients willpresentwith early stagedisease,approximately25 percent of these patients willsuccumbto their breast disease.

Among‘theprognosticfactors for breast cancer,early age at diagnosis (usuallylessthan or equal to age 35) and pre-menopausalstatus, has been found to be an adverseprognosticfactor. It is interestingwhen factored with size,axillarylymphnode status, and other biochemicalfactors, age loosesits significance.Nonetheless,youngerwomen who developbreast cancertend to have worse disease. What makes it more significantis that many of these William J. Pao, patients, due to their age,have fulltime occupationsand often have young MD children at home. Their deaths pose a problem for care givers.

One of the significantfactors in the advancefor cancer detectionhas been mammography. The technicalaspects,equipment and expertiseof physiciansinterpretingthe studieshas significantlyimprovedin the last 20 years. This is wherethe controversybegins.

Thus far, there have beenmore than 8 randomized studiesin looking at the efficacyof mammographyimprovingsurvival. To discusstheir findingsin detail is beyondthe scopeof this articlebut sufficeto say,their scientific conclusionthus far is as follows:

The first is that women 50 years of age or over definitelybenefitfrom screeningmammography. There is a significantreduction in mortality from breast cancer in women routinelyscreenedcompared to patients followedby their physiciansalone.

The secondisthat there is no specificsurvivaladvantagein the age group 40-49.

There could be many reasons why that is so. But an obviousone is that the greatestrisk of a woman to developingbreast cancer is her age. That is why by screeningolder women, one can pick up more cancercasesand hence make a differencein survival.

The National CancerInstitutethereforerecommendsscreeningmamm ography to beginyearlyat age 50 based on this scientificevidencethus far. The AmericanCancer Society,however,stillrecommendsyearlyscreeningat age40-49. You may ask, “Why?”. This is becausethe data in the same randomized studiesalso cannot disprovethe hypothesisthat screeningis not beneficialfor youngerpatients. Beingmore of a patient advocacygroup, the AmericanCancer Societyhas decidednot to changeits recommendationfor the last 20 years.

2 What is a clinicianto do? A good history and physicalis important. In patients with a strong familyhistory of breast cancer,history of endometrial cancer, etc., mammography may be needed at an earlierage. For most patients, screeningmammography is indicatedafter age40. We stilldo not have a national policy on breast cancer screening,but HMO or managed care practiceguidelinesmay later our practicebehavior beforelong. Longer follow-up of the randomized studiesmay also giveus the answerto the above questions.

WilliamJ.Pao, MD

1993 Breast Cancer

Age Age at Diagnosis

0-4 0 According to the 1993 National Cancer Data 5-9 0 Base, Breast Cancer is primarily a disease of 10 - 14 0 older patients, with approximately 75% of patients being over the age offifty. In 1992, 15 - 19 0 3,442 patients were diagnosed with breast 20 - 24 Ii cancer in Wisconsin, ofthese patients, 2,757 25-29 0 (20%) were 50 years ofage or older. St. Luke’s 30 - 34 Medical Center reports similar figures, in that 35-39 4 77% ofour patients were over fifty years of age 40-44 Ii when diagnosed with breast cancer. 45 - 49 50 - 54 16

55-59 I28 60-64 65 -69 43 70 - 74 30 75 - 79 80 - 84 I16 85+ I8 0 5 10 15 20 25 30 35 40 45

Number of Cases

Total Number of BreastCancer Cases Accessioned:24$

Female: 246 (99.2%) Male: 2 (00.8%)

(The 2 male caseswere patients diagnosed betweenthe agesof 65-69 and have been includedin the above numbers)

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The National Cancer Instituteestimatesthat 180,000 women are diagnosed with cancer of the breast each year. Breastcancerwillstrike 1 in 8 women in their lifetimes. Whilethe statisticsare alarming,data has shownthat death from breast cancer can be delayedor avertedby earlydetectionand treatment. High-qualityx-ray mammographyis clearlythe singlemost important factor in early detection. Unfortunately,a significantoverlapexistsin the mammographicmorphologyof lesions,and the nonspecificsignsof malignancyfrequentlymake benignconditionsindistinguishablefrom malignant processes. Only one in fivebiopsiesperformedfor mammographically-detected(nonpalpable)lesionsis found to be malignant! A nonsurgicaltechniquehas been developedthat takes core biopsiesof Mark Wenzel, M.D. mammographicallysuspiciousareas. The procedure,calledstereotacticcore biopsy,has been shown to be as accurateas traditional surgicalbiopsy followingneedlelocalization. Stereotacticcore biopsyusesx-ray imagesand computer analysisto localize the suspiciousarea in the breast. Initially,with the patient in the prone position,the breast is placedthrough a round openingin the biopsytable.

(Pleaserefer to Figure1) With the breast in compression,stereoviewsof the suspiciousarea are obtained. Usinga workstation, the radiologistentersthe location of the lesioninto the computer. Followingskinpreparation, local anesthetic,and a smallskin nick, a 14-gaugebiopsyneedleispassedinto the breast to a predetermineddepth usingthe coordinatesassignedby the computer. Stereoviewsare obtained prior to and followingbiopsyto ensure that the needlepassesthrough the lesion. (Pleasereferto Figure2) A mini- mum of six biopsiesare performeddependingon the adequacyof samples. Advantagesof stereotacticcore biopsyoverconventionalneedlelocalization and surgicalbiopsyinclude:significantlydecreasedcost, eliminationof the potential for disfigurement,and decreasedtime requiredfor arrangingand performingthe biopsy. The techniquehas the potentialto greatlyreducethe number of surgicalbiopsiesfor benignbreast disease. Stereotacticcore biopsy willplay an increasinglysignificantrole in the diagnosisand managementof breast cancer.

Mark Wenzel,M.D. i1

Figure1 Figure2 Stereotacticcore biopsy imagesof46-year-old woman with a nonpalpa ble 1.4 cm spiculated mass discoveredby mammography. Pathologic analysisrevealspoorly differentiatedinfiltrating duct cellcarcinoma.

5 PAThOLOGICFACTORSANDPROGNOSTICINDICATORS INBREASTCARCINOMA

A varietyof featureshave beenevaluatedas pathologicfactorsand prognostic indicatorsfor breastcarcinoma. The most important factorsthat could influencethe managementof breastcarcinomainclude: (A)morphologic aspects,(B)steroidreceptors,(C)immunohistochemicalmarkers,

(D) tumor oncogenes,(E)proliferativerate, and (F)nuclearmorphometry.

(A) MorphologicFeatures - Somelesionsthat constitutea risk factor for the subsequentdevelopmentof invasivebreastcarcinomainclude: intraductal hyperplasiaand scierosingadenosis(slightrisk),atypicalintraductal and lobular hyperplasia(moderaterisk),and intraductalcarcinomain-situ(high risk). The relativerisk doubleswhen there is a familyhistoryof breast cancer. Jorge G. Pellegrini, M.D. Patientswith tumors two centimetersin diameteror smaller(gross)have a significantlybetter prognosisand survivalthan larg5rtumors. Medullary, Tubular, Mucinous (Colloid),AdenoidCysticSecretory,Cribriformand Papillarycarcinomasare low grade histologiccancertypesassociatedwith a low frequencyor absenceof axillarynode metastasisand a relativelygood prognosis. Poorlydifferentiated,Signetring cellcarcinomas,Inflammatory carcinomasand Carcinosarcomasare generallyconsideredaggressive neoplasms. Stromalinvasionisthe most significantprognosticindicatorsince non-invasivecarcinomasare almostinvariablycured by mastectomy. Tumor grade is important in that highgradetumors have a higherfrequencyof axillarynode metastasis,tumor recurrencesand death from metastatic disease. The presenceof 25% or more intraductalcomponentis associated with decreasednodal metastasisand a more favorableprognosis. The prognosticsignificanceof lymphoplasmacytichost responseiscontroversial. Lymphatic,blood vesseland perineuralinvasionare prognostically unfavorablefindingsin node-negativepatientstreated by mastectomy. Regardingaxillarylymphnodesstatus,the ten year surgicalfailurefor patients is 86.5% with four or more positivenodes, 64.5% with one to three positivenodes and 24% with no positivenodes. The presenceof gross,rather than microscopicmetastasisin thesenodes,adverselyaffectsthe prognosis. The presenceof metastatictumor in internalmammarynodes,especially when associatedwith axillaryand supraclavicularnodes,portends an ominousoutlook. Unfavorableprognosisalso includeextranodal tissueextensionof tumor in patientswith three or fewerinvolvednodes and involvementof the axillaryapicallymphnodes.

(B)SteroidReceptors - Determinationof estrogenreceptors(ER)and progesteronereceptors(PR)in invasivebreastcarcinomasprior to therapeutic manipulationshas becomestandard practice. Tumorsthat are better differen tiated are more likelyto be ER positiveand PR negativityhas correlatedwell with highgradetumors. Patientswith ER and PR positivecarcinomashave a better overallsurvivalthan patientswith only one negativereceptor or patientswith ER and PR negativecarcinomas. There is indicationthat PR correlatesbetterthan ER with tumor recurrenceregardlessof lymphnode status and that PR negativepatientshave a shorter diseasefreeintervalthan PR positivepatients.

(C)ImmunohistochemicalMarkers - BETA-i Glycoprotein(SP-i)positive tumors have a higherfrequencyof axillarynode metastases. Tumor cells reactiveto two specificLectins(bloodgroup isoantigens)have significantly reducedrecurrence-freeand overallsurvival. Vimentinhas beencorrelated with tumor grade and has beensignificantlyassociatedwith a highergrowth rate as measuredwith the Ki-67antibody.

(D)Oncogenes- Insightinto the geneticchangesinvolvedin the development and progressionof malignantneoplasmshas beengainedfrom the study of oncogenes. Diseasefreesurvivalis significantlyreducedin C-erbB-2(HER- 2/neu)positivepatientswith axillarymetastasesbut not amongthose with

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RECONSTRUCTION/PLASTICSURGERYFOR BREASTCANCER

Rehabilitationof the breastcancerpatient in the 90’sfrequentlyinvolves reconstructionfollowingmastectomy. Many women find an external prosthesisunsatisfactoryfor a varietyof reasons. Though not a perfect replacement,a reconstructedbreastwillallowthe patient greater freedomof clothingand activity. Numerous studiessupport the efficacyof breast reconstructionfollowingmodifiedradicalmastectomy. Patientsatisfactionis quite high, over 90% in most studies.

A reviewof patientstreated at St.Luke’sMedicalCenterin 1928 and in 1993 have revealedcertaintrends. In 1988, a total of 15 patients underwent reconstructionout of a total of 188 seenand treated for primary carcinomaof Paul W. the breast,for a total of 7.9%. In 1993, 19 patientsor 7.6% of the total 248 Loewenstein, MD women with breastcancer,underwentreconstruction. This probably reflects two trends, one would be the smallerpool of patients availablefor reconstruc tion becauseof the greatertrend toward breast conèrvation. Out of this smallerpool, however,more women do seemto be optingfor reconstruction. The basictechniquesfor reconstructionhave beenavailablefor the last 10 years. Refinementsand improvements,however,continueto take place. Improvementsin the surfacecharacteristicsof implantshavegenerallyledto softer,more natural resultswith reconstruction. Bothsalineand gelfilled implantsare currentlyavailablefor the patient undergoingbreast reconstruction. Companiesinvolvedin the manufactureof implantsare workingwith materialthat is bettertolerated by the patient and more radiographically“friendly”.

Type of Reconstruction

198$ 1993 (19 Patients) (22 Patients) 59%

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79 % (15) Implant (9) Implant or or Tissue Expander Tissue Expander

10 Another trend that is occurringis that toward usingautologoustissue. In 1988, only 4 out of the 19 patients underwentTRAM (TransverseRectus AbdominousMusculocutaneous)flap reconstruction. The remaining15 all were reconstructedwith implantswith or without a firststageuseof tissue expander. In 1993, TRAM flaps outnumberedimplant reconstructionby 13 to 9. Part of this no doubt is due to the negativepublicityurrounding breast implants. On the other hand, most studiessupport the conclusionthat reconstructionwith the TRAM flap leadsto a better cosmeticresult.

Another trend observedis the increasingperformanceof breastreconstruction at the time of the mastectomy. Many studiessupport the safetyof this type of a procedure. The benefitto the patient is now unquestioned. In 192$,ten of the reconstructionswere done immediatelyand 9 in a delayedfashion. In 1993, 12 reconstructionswere done immediatelyand only4 in a delayed fashion. A Finally,the widespreaduse of the TRAM flap has led to the abilityto salvage the patient with chestwall recurrencefollowingradiation. Severalpatients have undergone extensivechestwall resectionswhich can be reconstructed usingthe TRAM flap. In conclusion,we have seenthat Milwaukeereflectsnational trends in the treatment of breast cancer. Estimatesof the numbers undergoing reconstructionnationwide range from S to 20%. There are definitetrends toward the greater use of autologoustissue,primarilythe TRAM flap,and reconstructionbeingdone at the time of the mastectomy.

Paul W. Loewenstein,MD

Timing of Reconstruction 1988 1993 (19 Patients) (22 Patients) 47% I (9) Delayed A 18% L:______(4) Delayed

82% (18)

(10) Immediate

11 CANCEROFTHEBREAST: THEROLEOFRADIATIONThERAPY

The useof ionizingradiationto treat patientswithcancerof the breaststarted withina fewyearsof the discoveryof X-raysbyWilhelmRoentgenin 1895. Earlypractitionersof radiationtherapybenefitedtheirpatientsbyimproving the localcontrolof breastcancerand relievingor decreasingtheir symptoms producedby advanceddisease.Modernradiotherapyrationaland techniques pursue‘thesesamegoalsforpatients,but with a betterdefinedunderstanding of how to morefrequentlyachievethe desiredpatientoutcomeswiththe least treatmentrelatedacuteand longtermmorbidity. Additionally,newquestionsabout the applicationof radiationtherapyand/or methodsof deliveryfor breastcancerpatientsare beingaskedwith the advent Marcia J.S. of morelimitedsurgicaltechniques,betterscreeningmethodswhichidentify Richards, M.D. earlierdisease,and systemictreatmentseffectivein preventingand/ordelaying distantrelapse. Many issuesposedbythesechangesin breastcancerand its treatmentare currentlybeingaddressedin clinicaltrials in whichpatientsat St.Luke’smayparticipate.

Post-operativeradiationtherapyfor breastcanceris utilizedto improvelocal control. It is deliveredfollowingbreastconservingsurgeryin patientswith earlycancer,aftermastectomyin patientswith largeprimarytumors (>5 cm) and/orwith extensiveregionalnodeinvolvement(>4nodesor 25% of axillary lymphnodesinvolved).In both situations,randomizedtrialshave documenteda reductionin the localrecurrencerate from20-40% without post-operativeradiationto 5-10% with post operativeradiationat 5-10year follow-up.No definitebenefiton survivalisclearlyapparent,but achieving localcontrol,consideringthe problemswhichmaybe associatedwith uncontrolledlocaldisease,addssignificantlyto the potentialqualityof an individual’slife.

Palliativeradiationtherapyfor breastcanceris utilizedto relievesymptomsin patientswith advanceddisease.Occasionallythismay be aggressivelocal treatmentin patientswith advanceddisease.Thisis somethingwhichis justifiedin suchpatientswithcancerof the breastbecauseof occasionallong term survival,evenwith locallyadvanceddiseaseat diagnosis.Shorter palliativecourses,usuallyfrom 1-3weeksare morecommonlygivento patientswith distantmetastasisto alleviatesymptomssuchas bonepain, neurologicproblemsfrommetastaticdisease,or symptomsfromvisceral obstruction. Improvementin lifequality,as measuredby symptomrelief, shouldbeexpectedin 80% of the patients. Thisis usuallyachievedwith a smallinvestmentof time,competitivecosts,and minimalvolumeresultingin limitedtreatmentsideeffectsfor the patient. Whenthe patient’ssymptoms originatefromlimitedareasof diseaseinvolvement,radiationtreatmentis oftenpreferableto systemicmanagementalonebecauseof the lackof whole bodysideeffectsduringtreatment,the rapidityof responseof symptomatol ogy,and the localeradicationofthe diseaseprocess. In manycasesthe need for continuedsystemicmanagementof symptomsis significantlyreducedor eliminated.

12 Current radiation researchissuesincludeeffortsto decreasethe late morbidity of post-operativeradiation through improvedtechniquesin radiation planning and effortsto limit both the treatment volumesand dosesbased on patient parameters. Issuesrelated to the timingof systemictherapy and integrationwith radiation are also under investigation. Bettermethodsfor patient selectionof differentlocaltreatment options basedon pathologicand prognosticstudiesof the tumor are also beingstudied. The use of radiation therapy in non-invasivebreast canceris under extensiveevaluation,since between5-10% of the women diagnosedwith breast cancernow presentwith this histologicpattern.

In summary, radiation therapy’smajor achievementis improvementin quality of lifefor patients with cancer of the breast. For women with earlydisease, breast conservingtreatment is possibleand oftenpreferable,and for patients with advanced diseaselocal symptomsare usuallyrelieved.

Marcia J.S. Richards,M.D.

198$ Breast Cancer - 1993 Breast Cancer - General Summary Stage General Summary Stage 48.9% 54M%

Number of Cases Percent Number of Cases Percent In situ 26 13.8% In situ 24 9.7% Local 92 48.9% Local 134 54.0% Regional 50 26.6% Regional 70 28.2% Distant 12 6.4% Distant 16 6.5% I ,-O/ Unknown 8 4.3% Unknown 4 1.0 /0

188 248

The incidence of breast cancer has been rising dramatically in the United States since 1982, based on data collected by the Surveillance, Epidemiology, and End Results (SEER)program ofthe National Cancer Institute. Over this period of time, incidence rates for in situ and localized invasive tumors have been said to increase, while rates for regional and distant tumors have remained stable. According to the National Cancer Data Base (NCDB), the percentage of in situ cancers increased between 1985 and 1988 but was essentially constant between 1988 and 1990. Because in situ carcinoma is identified only by mammography, this data suggests a plateau in the use ofmammographic screening. When reviewing St. Luke’s data, we note an increase in the incidence of breast cancer from 1988 to 1993 and little change in the percentage of regional and distant stage patients from 1988 to 1993, but unlike the NCDB, we note a decrease in the percentage ofpatients diagnosed with in situ carcinoma.

13 SYSTEMICTHERAPYFORBREASTCANCER

Surgeryand radiation are LOCALtreatmentsfor breastcancer,while chemotherapyand hormonal agentsrepresenta SYSTEMICapproach. Immunotherapyis also a systemicmodalitybut is stillexperimental.

Treatment is eitherADJUVANTor PALLIATIVE.In the former, all palpable or grossdiseasehas beensurgicallyremovedand onlymicroscopicdisease remains. Adjuvanttreatment thereforeaimsto curethe patient of her breast cancerby preventinga relapse. In palliativetreatment however,the breast canceris not curableand the aim of therapy isto control the disease,thereby eliminatingsymptomsand prolonginglife. When breastcancerhas metastasizedoutsideof the breast,it is generallyincurable. Whateverthe aim of therapy,the drugsusedmay be the same. The most frequentlyusedhormonal agentsin breas;cancerare Tamoxifen,an anti-estrogen,and Megace,a progesterone-likedrug. Thesedrugs bind to proteinson the surfaceof breastcancercellsknown as hormone receptorsand theoreticallyinterferewith cellgrowth. Typicallythesedrugswork slowly and it may take weeksto seea response. Bothare in pillform and are relativelyeasyto tolerate. Tamoxifenmay causeor aggravate“hot flashes”in a third of women. Other sideeffectsare veryinfrequentbut potentially serious,such as blood clots,uterinecancer,and effectson the retina. Megace typicallystimulatesappetite,causessomefluidretention and may also cause blood clots. . Usedin the adjuvant setting,Tamoxifenisthe hormonal drug of choice. Followingbreast surgery(mastectomyor lumpectomy),a patient whose cancercellsdemonstrateestrogenand progesteronereceptorsis prescribed20 mg/dayof Tamoxifen,for 2 to S years. Other “good sideeffects”include about a 40% decreasein the risk of a secondbreastcancer,a decreasein myocardialinfarctionand protectionfrom osteoporosis. In the palliative setting,eitherhormonal agentis givenfor 8 to 12 weeks. If the patient responds,it iscontinuedindefinitelyor until the breastcancerbecomes resistantto the drug. A patient who achievesa significantresponseto one hormonal agent is verylikelyto have another responseto a second hormonal agent.

Breastcanceris fairlysensitiveto chemotherapy. There are at least 15 drugs commerciallyavailablethat may be used. The most activeare Doxorubicin

(Adriamycin)and Taxol. Chemotherapyworks more quicklythan hormonal agentsand responsesare more dramatic. In the adjuvant setting, chemotherapyis favoredoverhormoneswhen the patient isyounger

(pre-menopausal),when the cancerlackshormone receptorsand when the risk of relapseisveryhigh (e.g.many axillarylymphnodes with cancer). Usuallycombinationsof 3 drugsare used,suchas “CMF” (cyclophosphamide,methotrexateand 5-flourouracil). Theseare givenin variousschedulesonce or twicea month for at least6 cycles. In recentyears it has beenfound that dose-intensity,or givingenoughof thesedrugs to substantiallylowerthe white blood cellcount, is as important as which drugs are used. When goingfor a cure, it is important to try not to reduce chemotherapydoses,and to deliverthese on schedule. Autologousbone marrow transplantation representsthe greatestdose-intensityof chemotherapy. It is stillbeingstudiedand iscurrentlyreservedfor patients whosechanceof relapseis virtuallycertain.

14 ______

Sideeffectscommon to most of thesecombinationsincludesomenausea,hair loss,low white cellcount (and thereforeincreasedrisk of infection),mucositis and fatigue. Adriamycinalso has the additionaltoxicityof affectingthe heart muscle,usuallyafter cumulativelargedoses.

Chemotherapyfor metastatic breast canceris usedwhen the diseaseis hor mone resistant,when there is life-threateningvisceraldisease(e.g.livermetas tasis),and in the youngerpatient. Therapy is continued untilthe maximum responseis achievedor the cancer becomesresistant. Often,patientswill receivea combination of both chemotherapyand hormones,eitherall at once, or in sequence. In summary, chemotherapyand hormonal therapy for breastcancertreats the entire patient. The treatment should be individualizedto the patient and the breast cancer. New drugs are neededto overcomeresistantcancersand to crossthe blood-brain barrier.

Margery Strack,MD

SLMC 5-Year Survival - Breast Cancer By GeneralSummary PERCENTAGE OF CASES 120

100 x

80 \\

ALL CASES 4C — LOCAL A REGIONAL 2C E— DISTANT N< * . —z—INSITU

1 2 3 4 5 YEARS OF SURVVAL Comparison of Breast Cancer Survival Rates for SLMC and SEER Stage SLMC SEER All 76.4% 78% Local 84.4% 93% Regional 60.7% 71% Distant 14.5% 12%

SEER survival rates, per Cancer Facts & Figures - 1993, are based on patients diagnosed between 1983- 87, and followed through 1989. SLMC survival rates are based on 150 analytic breast cancer patients diagnosed and/or treated in 1988 and followed through 1993.

According to 1981 -1987 SEER (Surveillance, Epidemiology and End Results) data, printed within Cancer Facts & Figures - 1993: The S year survival rate for localized breast cancer has risen from 78% in the 1940’s to 93 % today. In situ (non-invasive) breast cancer survival approaches 100% . If the cancer has spread regionally, however, the survival rate is 71%, and for persons with distant metastases, the survival rate is 12%. Survival rates for St. Luke’s patients diagnosed in 1920 are displayed above and are similar to those published by SEER. AJCC Stage at Diagnosis for Breast Cancer

198$ 1993

I—_____ — 1.6% 41.1% 36.7 Number of Cases Percent Number of Cases Percent A In situ 11 8.9% In situ 24 9.7% Stage I 46 37.1% Stage I 93 37.5% Stage II 51 41.1% Stage II 91 36.7% Stage III 8 6.5% Stage III 17 6.9% Stage IV 6 4.8% Stage IV 15 6.0% Unknown 2 1.6% Unknown 8 3.2%

124 248

(64 Breast Cancer Cases from 1988 were not staged)

Accordingto an articlefrom Ca-ACancerJournal for Clinicians:Trialshaveshowed comparableoutcomes for patients treated with CS + RT (conservativesurgery + radiation therapy)and with mastectomy. At a National InstitutesofHealth ConsensusDevelopmentConferenceon the treatment ofearly-stagebreast cancerinJune 1990, data on CS + RT and mastectomywas reviewed. Basedon the resultsofthe trials,the panel concludedthat breast conservationtreatment isan appropriate method ofprimary therapy for the majority ofwomen with StageI and StageII breast cancer,and ispreferablebecauseit providessurvival equivalentto total mastectomyand axillarydissectionwhilepreservingthe breast. Histology,patient age, tumor size,physicalconditionand ofcourse, patient preferencemust be consideredwhen treatment is being planned. Thegraphs above show that over 75% ofbreast cancerpatients diagnosedor treated hereat St. Luke’sin 1988 and in 1993 wereStageI or II and m have beeneligiblefor conservativesurgery + radiation therapy.

AJCC STAGE BY FIRST COURSE OF TREATMENT - 1993 BREAST CANCER

TREATMENT IN SITU STAGE I STAGE II STAGE ifi STAGE IV UNKNOWN

Surgeryonly 12 44 17 2 0 1 Radiation only 1 1 0 0 0 0 Hormones only 0 1 0 0 2 0 Surg,Rad 11 17 5 1 0 0 Surg, Chemo 0 5 18 4 3 0 Surg,Horm 0 6 14 0 0 2 Rad,Chemo 0 0 0 0 1 0 Chemo, Horm 0 0 0 0 2 0 Surg,Chemo, BRM 0 0 3 0 0 0 Surg,Rad, Chemo 0 3 13 4 0 0 Surg,Rad, Horm 0 14 7 1 1 0 Surg, Chemo, Horm 0 0 5 1 1 0 Rad, Chemo, Horm 0 0 0 0 2 0 Surg,Rad, Chemo, Other 0 0 1 1 0 0 Surg,Rad, Chemo, BRM 0 0 1 0 0 0 Surg,Rad, Chemo, Horm 0 2 5 2 0 1 None 0 0 0 0 3 4

TOTALS 24 93 91 17 15 8 16 17

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Marija Vince AUTOLOGOUSBONEMARROWREINFUSION FORBREASTCANCER

High dosechemotherapywith autologousbone marrow/peripheralstemcell reinfusionhas beenavailableat St.Luke’ssince1991 as a therapeuticoption for somewomen with breastcancer. SinceApril 1991 more than 65 women have undergonethis treatment here. Thistherapy can offerimprovements (overconventionalchemotherapy/radiationtherapy)in longterm survivalin women with StageIIIor highrisk StageII disease. A selectgroup of women with locallyrecurrent or metastaticdisease(thosewith minimaltumor burden and chemotherapyresponsivetumors) may also benefitfrom this approach.

This treatment is based on high dosechemotherapy. The reinfusionof autologoushematopoieticcellsiscarriedout as a rescuefrom the marrow Robert Taylor, toxic sideeffectsof the chemotherapy. The chemotherapyand reinfusionare MD done on an inpatientbasis,with a 21 day averagelengthof stay. For most patients,radiation therapy isgivento the area of originaldiseaseon an outpatient basisbeginning40-50 dayspost reinfusion. This is d’onein order to help preventlocalrecurrence. Whilethis therapy offershope for many womenwith aggressivebreastcancer, it is not without risksand sideeffects. Most patientswillexperiencenausea, vomiting,diarrhea and other chemotherapyrelatedsideeffects. Patientsare at risk for infectionand bleedingduringthe period of myelosuppression followingthe treatment. Diseaserecurrence,in spiteof aggressivetherapy, is also possible. Futurework in the AutologousBoneMarrow Transplant Programwillfocuson waysto furtherreducetreatment relatedtoxicityand decreasethe incidenceof recurrencefollowinghigh dosechemotherapy/stem cellreinfusion.

Robert Taylor, MD

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18 St LUKE’SMEDICALCENTER ABMI PROGRAM

The first Autologous Eone Marrow Transplant patient was “transplanted” at St. Luke’s Medical Center on April 5, 1990. As ofJune of 1994, 108 patients have undergone treatment for the following diseases:

1990 1991 1992 1993 1994 TOTAL Non-Hodgkin’s Lymphoma 4 2 10 4 2 22

Hodgkin’s Disease S 1 2 0 2 10

Multiple Myeloma 0 0 2 1 2 5

Other (Sarcoma, Glioma, 0 1 2 1 1 5 Ovarian cancer)

Breast Cancer, Adjuvant 0 1 14 10 5 30 A Breast Cancer, Advanced 0 8 10 14 4 36 TOTAL 9 13 40 30 16 108

All statistics are non-actuarial. Patients lessthan 3 months post ABMT are not included in the analysis below. Non-Hodgkin’s Lymphoma (N = 21) Survival: 13 pts (62%) Disease Free Survival:12 pts (57%) Median Survival: 19 mths Median Disease Free Survival: 19.5 mths Survival Range: 4-50 mths Disease Free SurvivalRange: 4-50 mths

Hodgkin’s Disease (N = 10) Survival: 7 pts (70%) Disease Free Survival:7 pts (70%) Median Survival:2$ mths Median Disease Free Survival:2$ mths Survival Range: 4-46 mths Disease Free SurvivalRange: 4-46 mths

Multiple Myeloma (N = 3) Survival:2 pts (66%) Disease Free Survival:1 Pt (33%) Median Survival 14 mths Median Disease Free Survival:14 mths

Breast Cancer, Adjuvant (N = 2$) Survival:26 pts (92%) Disease Free Survival:23 pts (82%) Median Survival: 17 mths Median Disease Free Survival:16 mths Survival Range: 3-31 months Disease Free SurvivalRange: 3-31 mths

Breast Cancer, Advanced (N = 36) Survival: 14 pts (38%) Disease Free Survival: 10 pts (27%) Median Survival: 9.5 mths Median Disease Free Survival:6 mths Survival Range: 3-32 mths Disease Free SurvivalRange: 3-32 mths

For more information regarding the ABMT program at St. Luke’sMedical Center, please call 649-6472 or 649-6540.

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20 FORMERPRESIDENTGERAlDFORD’SDAUGHTERFEATURED ATBREASTCANGERAWARENESSPROGRAM

In recognitionof BreastCancer AwarenessMonth in October 1993, St.Luke’sMedical Center Cancer Program presenteda freepubliceducation program featuringSusanFord Bales,the daughter of formerPresidentGerald Ford and Mrs. BettyFord. Susan,a national spokespersonfor breast cancerawarenessfor the past nine years, is recognizedas one of the most visibleadvocatesfor breastcancer awareness. In her movingpresentation,sheshared her story as the daughter of a woman with breast cancer,emphasizingthe importanceof earlydetection and proper treatment. Marcia J.S.Richards,M.D., MedicalDirectorof Radiation Oncologyat St. Luke’s,also spoke on the latestadvancementsin breast cancertreatment and research. The event drew an audienceof 300 women and men to the Italian Community Center. In addition to the educationalpresentations,St.Luke’s cancercare specialistswere availableat educationalbooths to provide information about breast cancerprevention,detection,screening and treatment. Earlierin the day, Susandiscussedher story with reportersand representatives from the Lombardi Foundation. The program was made possiblethrough support from the VinceLombardi Memorial Classic.

Mary Fields

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22 SUPPORTGROUPSOFFEREDAl St LUKE’SMEDICALCENTER

Many ongoingsupportgroups are offeredby St.Luke’sMedicalCenterto the surrounding community. The support groups availablecater to a widevariety of needs. Here are the groups offeredfor cancersupport and griefsupport: Cancer Support

“Kids Connection,”A support group to help children,ages5 through 15, cope when a parent has cancer. FREE. Registrationis required. Callthe Vince Lombardi Cancer Hotline at 649-7200, for specifictimesand dates.

“Make Today Count,”A support group for familiesand personswith cancer or other life-threateningillnesses,sponsoredby St.Luke’sMedicalCenter,it is held the fourth Thursday of each month from 7:30-9p.m. at CudahyUnited

Methodist Church, 5865 5. LakeDr. FREE. Callthe VinceLombardiCancer A Hotline at 649-7200.

“Your Caring Connection,” A support group for patients experiencingcancer, their familiesand friends,is held at the VinceLombardi Cancer Clinic,at St.Luke’sMedical Center, on the secondand fourth Monday of eachmonth, from 6:30-8 p.m. FREE. Call the Vince Lombardi Cancer Hotline at 649-7200.

“Ovarian Cancer Awareness Group,” A support group for women with ovarian cancer,their familiesand women who feelat risk for ovariancancer, is held at St. Luke’sMedical Center,the firstTuesdayof each month from 6:30-8 p.m. FREE. Call the Vince Lombardi Cancer Hotline at 649-7200. “BoneMarrow Support Group,” meetson the firstThursdayof each month from 6:30-8 p.m. at the Vince Lombardi Cancer Clinic. For more information, callthe VinceLombardi CancerHotline at 649-7200.

Grief Support Groups:

“Loss of Parent for Adults,” support group meets Thursdays for six weeks,from 6:30-8:30p.m., is held at St.Luke’sMedicalCenter. A $10 donation is suggested, but may be waived. For more information, call 649-7315.

“Loss of a Parent for Children,” call St. Luke’sMedical Center at 649-7315 for specificdates and times.

“Recently Widowed,” A support group meets on Tuesdays from 1-3 or 7-9 p.m. at St. Luke’s Medical Center. A $10 donation is suggested,but may be waived. For more information,call 649-7315.

“Survivors Helping Survivors,” A self-helpgroup for persons mourning the death of a loved one by suicide, is held the second Tuesday of each month from 7-9 p.m. at St. Luke’sMedical Center. FREE. For more information, call 649-6230.

For more information on these and other support groups available at St. Luke’s medical center, please call 649-7114.

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24 ______

1993 CANCER ANNUAL REPORT STATISTICS

SITE 1993 Site Distribution Breast 124$ Skin Lung ) Prostate Colon Bladder 1 Rectum, Rectosigmoid Junction 7 Lymph Nodes Unknown and ill-Defined Sites Kidney, Renal Pelvis Hematopoietic System Endometrium Pancreas Brain, CNS Lip, Oral Cavity, Pharynx c_ I Ovary Cervix z Stomach & ill-Defined Digestive Organs Larynx Liver, Gallbladder, Bile Ducts Male Genitalia Thyroid Esophagus Soft Tissue Thymus, Heart, Mediastinum Female Genitalia I Bone 7 Eye & Lacrimal Gland 7 Small Intestine Trachea Accessory Sinuses Peritoneum 1 0 40 80 120 160 200 240 280 Number of Cases

Class Of Case At Diagnosis

Number Of Cases Class Of Case Class 3 9 Class 0 -First Diagnosed At This Facility Class 2 And All First Course Of Therapy - [30.1%) Elsewhere

875 Class 1 -First Diagnosed And All Or Part Of First Course Of Therapy Done At This Facility 446 Class 2 -First Diagnosed ElsewhereAnd All Or Part Of First Course Of Therapy Done At This Facility (59%)

151 Class 3 -First Diagnosed And All Of First Course Of Therapy Elsewhere, Subsequent Courses Of Therapy At This Facility

2 Class S -First Diagnosed At Autopsy, An Incidental Finding Of Cancer At Time Autopsy Performed

1483 25 ______]_____

1993 CANCER ANNUAL REPORT STATISTICS

Total number of Patients Accessioned:1,483 1993 New Case Distribution By Age 0-4 Female: 754 (50.8%) 5-9 Male: 729 (49.2%) 10 - 14 0 15 - 19 0 20 -24 25 - 29 30-34 DIAGNOSTIC CONFIRMATION . 0 tz 40-44 55 Type of Number of 45-49 Confirmation Cases/Percent 50-54 4 55-59 I i POSITIVEHISTOLOGY 1386 (93.5%) 60 - 64 (specimensfrom biopsy, -‘ 65 - 69 127 frozen section,surgery,autopsy, 70- 74 ‘-‘.J orD&C) 75 - 79 9 80 - 84 85+ POSITIVECYTOLOGY 53 (3.6%) 0 40 80 120 160 200 240 280 (microscopicexamination of cells; Number of Cases sputum smears, bronchial brushings, washings, secretions, and fluids)

POSITIVEMICROSCOPIC 1 (.1%)

(cases microscopicallyconfirmed but without details on the method) 15 Most Frequent Histologies - 1993 Hito1ogy Adenocarcinoma 10 LABORATORY TEST! Infiltrating Duct Cell Carcinoma MARKER STUDY 2 (.1%) Squamous Cell Carcinoma 40 (based on lab tests or marker studies Basal Cell Carcinoma Carcinoma clinicallydiagnostic for cancer) Small Cell Carcinoma Large Cell Carcinoma ) VISUALCONFIRMATION 6 (.4%) Malignant Melanoma (surgical exploration or use of scopes Papillary Transitional Cell Carcinoma 127 when visualization not supplemented Transitional Cell Carcinoma I26 Malignant Lymphoma by positive histology or cytology) Lobular Carcinoma Papillary Adenocarcinoma RADIOGRAPHIC 18 (1.2%) Malignant Lymphoma, Large Cell, L_ Ineraductal Carcinoma, Non-infiltrating (based on imaging techniques for All others (105 with counts not displayed) cases where there is no positive 0 50 100 150 200 250 300 350 400 450 histology or cytology) Number of Cases

CLINICAL DIAGNOSIS 13 ( .9%) (clinicalmethods not mentioned Over 97% ofall SLMC cancer cases in 1993 were microscopically previouslyfor cases where there diagnosed. This helped determine the cell type and other is no positivehistologyor cytology) characteristics of the tumor which is used in treatment planning and sometimes to identify the primary site or the extent of tumor UNKNOWN 4 (.3%) spread. Cancers not diagnosed microscopically tended to be cases (No information available as to or which surgery was not f performed or for which further whether or not work-up was not provided microscopically due to the patient’s refusal or death, confirmed) or on the advise ofthe physician.

26 27 is that those with data their distant cancer situ Treatment cancers patients between 1.6% Unkown In Unkown with from skin diagnosed situ while for 9.7% skin cancer 4.9% Wisconsin

were STATISTICS Distant of prognosis. the averaging area, Distant diagnosed to of L65%

c______In — 1993 state diagnosis prostate small - patients were facility 28.2% Regional at a and 1992 of our our

stage Sites of

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with

REPORT

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lung, (248 of —_-—-—4.2% radiotherapy Center) diagnosis of 1993, by

exclude Sites 17% comparison in figures

or 5

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Breast Summary Medical of that SEER Other percentage

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data. iop surgery and time 20.4%—” Regional reveal Luke’s by the

larger for SEER. (St. a at disease.

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spread Stage SEER SEER often

/0 1993 WI Luke’s

with CANCER I Reporting 37% 53% 1993 and 15% Wisconsin 43% 23% St. tumor situ more 1992 of 1983-87

1983-87 Diagnosis is treatment. ofln both

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cases. 1993 them. between and diagnosed extent /0 0/ than spread A exclusion -t 57%

many 26% Stage were systemic to the made SLMC 1992W1 in include is due Wisconsin 16.9% 53.6% 20.4% available) before disease we more the 53.6% ‘1993 100% cancer, SEER and local SLMC

of Summary and equal figures and since 54% 6.5% require 28.2% not comparison diagnosed with totals types do ‘p1993 A Stages. disease current

spread General most available Wisconsin cancers situ Unkown Percentages * Local Regional Distant (most diagnosed disease. of For of have in published Local Regional not Distant 1993CANCERANNUALREPORTSTATISTICS

Skin (216 patients) SLMC Percent In situ 10 4.6% Local 201 93.1% 4.6% Regional 2 .9% 1’ .5% 93.1 %4 0.9% Local Unknown Distant Regional Unkown 2 .9%

216 Stageat diagnosis comparisons for skin carcinomas are not available for state and national figures. These figures include Basal Cell Carcinomas and Squamous Cell Carcinomas in addition to Melanomas and other skin cancers. Lung (210 patients)

‘1993SLMC 1992W! 19$3-87SEER 25.3 %—i 3.8% Regional Unkown Local 39% 22% 16% Regional 25% 30% 32% T__31.9% Distant Distant 31.9% 38% 37%

29 Unkown 4.$%Unkown Distant Distant

Regional STATISTICS 18.4% A 10.2%

10.2% patients)

patients)

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Colon Prostate 74.8% Local

% ANNUAL 33

Regional CANCER 34% 14% 18% 40% 20% 58% 1983-87SEER

1983-$7SEER 1993 7% 16% 33% 15% 41% 69% 1992W1 1992W1 SLMC SLMC 33% 18.4% 36.9% 10.2% 10.2% 74.8% ‘1993 ‘p1993 Local Regional Distant Regional Distant Local of

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Unknown Lymphoma Thyroid Prostate Kidney

Conferences Testis HEAD disciplinary were ethmoid,

trachea, Neck

CONFERENCES

CANCER

LUKE’S

SI.

30 St LUKE’SCANCERCONFERENCES

June 7, 1993 The Role of Mammography Edward A. Sickles,M.D. Professor of Radiology University of California - San Francisco

Sponsored by the Schroeder Fellov Program in Clinical Oncology

September 18, 1993 The First Annual St. Luke’sSchroeder Cancer Conference For Physicians

Sponsored by the Schroeder FellowsProgram in Clinical Oncology

“The Management of Esophageal Cancer” David J. Sugarbaker, M.D. Associate Professor of Surgery Chief, Division of Thoracic Surgery Lung Transplant Program Harvard Medical School Brigham and Women’s Hospital Boston, MA

“PSA and Prostate Cancer: What Physicians Need To Know” Joseph E. Oesterling, M.D. Associate Professor of Urology Mayo Clinic Rochester, MN Editor-in-Chief, Urology

“Hereditary Cancer and Cancer Genetics” Robert R. Lebel, M.D. Genetic Services Elmhurst, IL

“The Management of Minimally Invasive Breast Cancer” Richard G. Margolese, M.D., FRCS (C) McGill University Director of Clinical Oncology McGill Comprehensive Cancer Center Director, Department of Oncology Sir Mortimer B. Davis Jewish General Hospital Montreal (Quebec), Canada

September 29, 1993 High Dose Chemotherapy in Primary and Metastatic Breast Cancer William Peters, M.D.

October 7, 1993 The Immunotherapy of Solid Tumors D. Schwartzentruber, M.D. SecurityBank Lecture

31 I’,’

COMMUNiTYEDUCATION

Ianuary 21, 1993 “CancerPreventionand EarlyDetection” Paul P. Hartlaub, MD, Assistant Professor, Family Medicine & Practice Sharon Thompson, RegisteredDietitian BeckyPogacor, RN, Pulmonary Medicine Kerry A. Twite, RN, ClinicalNurse Specialist

March 1, 1993 “Prostate Cancer - What You Need to Know” Stuart Fine, MD, Urologist

May 20, 1993 “Survivorship: LivingWith, Through, and Beyond Cancer” Susan Leigh,RN, President of the National Coalition for Cancer Survivorship

July 22, 1993 “Skin Cancer: Advancements in Treatment Overview of Skin Cancer, Radiation Therapy & SkinCancer, Immunotherapy and Melanoma” Thomas J.Russell,MD James E. Bruckman, MD John P. Hanson, MD

32 GLOSSARY

AdjuvantChemotherapy:One or more anti-cancerdrugs usedin combinationwith (inadditionto) surgeryor radiation therapy as a part of cancertreatment.

AnalyticCases:Caseswhich are first diagnosedand/or giventheir firstcourseof treatment at St.Luke’sMedicalCenter.

Biopsy:A procedure where a pieceof tissueor fluid (a group of cells)is taken from a person’sbody and examinedwith a microscopeto seeif the cellsare normal or not. Bone Marrow: The soft, spongycenter of the bone, the “factory”that producesblood. BRM: (BiologicalResponseModifier)Any agentthat booststhe body’simmunesystemby stimulatingit, modifyingit or restoringit. Chemotherapy:Treatment with powerfuldrugsthat attack cancercells. ClinicalTrials: Studiesdesignedto evaluatepromisingnew treatmentsby helpingresearcherslearn which approachesare more effectivethan others. Combined Therapy: Refersto any combinationof surgery,radiation, chemotherapy,hormone therapy or other therapy administeredjointly as a singlecourseof treatment DiagnosticOnly: Cancer related treatment was not givendue to the patient refusingtreatment or his/hergeneralcondition being unsatisfactoryfor treatment. Diethyistilbestrol:(DES)A syntheticestrogeniccompound prescribedin the past to preventspontaneousabortion. Distant Stage:A neoplasmthat has spread to other organsor lymphnodesfrom the primarytumor. First Course Treatment: The tumor directedtreatments started withinthe firstfour months after diagnosis Immunotherapy:Useof the immunesystemor the products of the immunesystemto control, damage,or destroymalignant cells. In situ:A tumor classifiedmicroscopicallyas in situ, non-invasive,pre-invasive,non-infiltrating,intraductal,intraepithelialor intraepidermal LocalStage:Tumor restrictedto the organ of origin,but may be invasiveor infiltratingwithin the organ of origin Lump: A thicknessunder the skin that can be feltby the fingers,eitherby the person who has it or by a doctor. A lump can be a signof cancer, but most lumps are not cancerous. Lumpectomy:Surgicalremovalof the cancerousportion of the breastand a smallamount of surroundingtissue. Lymph:A nearly clear fluidcollectedfrom tissuesaround the body and returned to the blood via the lymphaticsystem Lymphedema:Unilateralor bilateraledemaof the extremitiesdue to accumulationof interstitialfluidas a result of stasisof lymph,which is secondaryto obstruction of lymphvesselsor disordersof the lymphnodes. LymphNodes: Smallbean-shapedstructuresscatteredalongthe vesselsof the lymphaticsystem. The nodesfilterbacteriaand cancercellsthat may travelthrough the system. Mammography: A low-doseX-ray of the breastthat can detectcancerin the earlystages. Metastasis:The spread of cancer from its originalsiteto distant areas. The cancercellsare carriedto distant sitesby blood and lymph.

Non-Analytical:Caseswhich are seenat St.Luke’sMedicalCenterafterthe first Courseof treatment. PalliativeTreatment: The use of medicalremidiesto relievepain, symptoms,and/or preventfurther complicationsrather than to cure. Partial Mastectomy:Surgicalremovalof up to one quarter of the breasttissueand all or some of the lymphnodes in the armpit. PrognosticIndicators:A symptomor signon which a prognosismay be based. Prone Position:Lyingfacedownward. Radiation Therapy: Treatment with high-energyradiation from x-raysor other sourcesof radiation that damagesor killscells. 33 and the by may further. nodes, no that overlying tissues or lymph wall spread cancer organs have axillary breast to of the abd@minal cancer. a wall, appears shape of lower surrounding history 1) and the chest 2 breast family a into the from and of 1 and create of disappearance origin tissue to on of or muscle Uses Cancer 3. Statistics organ menopause, Breast American cancer. Education Social No. Flap) sufficient the shrinkage combination for Georgia. late Committee the a underlying of 42, and Annual 1993, of American Publication, 3) often Education - the Inc., is Joint or Vol. 993, limits describe 1 Care Health Professional skin, Standards interval. to spread area the Inc., of 1. of Society, 1989. Education and menstruation, this 992, Publication, Used American 1 Professional implant. Patient of No. Musculocutaneous metastasis, Cancer, beyond Society, 1989. 1991. of extent from 1992. by Cancer breast 43, disease-free onset a and Edition, Inc., Breast the Inc., Department internal Vol. Novemeber tissue Education Professional May/June January/February Cancer nodes of Review size an early extended after Abdominus Mastectomy, disappearing. Inc., The American 1991. Fourth the has Society, Society, or age, Primary Georgia. Philadelphia, lymph Cancer, Annual Wisconsin as Statistics, of removal require cancer cancer. Rectus area. Inc., 1993, that American Clinicians, Clinicians, of to - Society, Professional CO., Cancer, Cancer Cancer The describe Base Following smaller such Georgia. for for Breast 1988, Atlanta, not regional of breast Health to 993, tumor of muscle Society, 1 2) return of Data A Figures Cancer for Inc., used (Transverse Factors Treatment, & Journal Journal Management Atlanta, The risk Growing Lippincott enough American Staging American Stage: Cancer Wisconsin term Cancer the Center Mastectomy: for Flap: Inc., J.B. Facts Statistics: in Society, A abdominus extension, Reconstruction American Cancer Cancer Factors: Surgical Epidemiology tissue.

GLOSSARY Radical fat Regional direct Recurrence: Regression: Risk increase Stage: satisfactory TRAM rectus The

REFERENCES Cancer Cancer, Manual Cancer Ca-A Society, Ca-A Conservation Issue, Cancer Services, The American Breast Publication, Publication, Cancer National 34 C>Ib

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