1. health and fitness
2. disease
3. cancer

RINGING THE
BELL FOR
CANCER PATIENTS
R I V E R S I D E W A LT E R
REED CANCER PROGRAM
2010
ANNUAL REVIEW
Riverside Walter Reed Cancer Program
Riverside Walter Reed Hospital has been treating cancer patients
on the Middle Peninsula since 2004. Treatment resources include
Surgery, Medical Oncology, Radiation Oncology and Supportive
Care measures.
Radiation Therapy is delivered via an External Beam Linear Accelerator. IMRT
is also available providing a more precise focusing of the beam, minimizing
the damage to surrounding tissues. Radiation oncologists consult National
Comprehensive Cancer Guidelines (NCCN) guidelines when developing treatment
plans.
Medical Oncology provides nine treatment chairs and one treatment bed for
chemotherapy outpatients. All Medical Oncologists at the Riverside Cancer Infusion
Center consult the National Comprehensive Cancer Network (NCCN) treatment
guidelines when making recommendations. In addition to providing custom
chemotherapy regimens, patients may also undergo diagnostic procedures such as
bone marrow biopsies if needed.
Community Outreach is an essential part of the Walter Reed Cancer Program. In
2010 the American Cancer Society Look Good Feel Better Program was established
at Walter Reed and is holding monthly meetings. This free program offers woman
an opportunity to improve their self esteem. Monthly cervical cancer screenings
are offered at the Gloucester-Mathews Free clinic as well. Cancer Services
Community Outreach continues to be an active participant at many other local
events and festivals providing information and awareness to the public.
Hospice is offered when treatment is no longer an option for a patient. A full
range of services are made available to the patient and their family. Patients can
maintain a close working relationship with their PCP and also utilize the service
of the hospice medical director, if the need should arise. The patient also has the
benefit of the hospice’s expertise in palliative care. By acknowledging the physical
and emotional needs of the patient, family and caregivers, hospice is dedicated
to providing information to assist in maintaining the highest possible levels of
functioning and to promote comfort in the patient’s place of residence. Hospice
strives to improve the quality of life for the terminally ill and their loved ones. Review of 2009 Accessions
The Riverside Cancer Registry began collecting and reporting data for Riverside
Walter Reed Hospital in 2007. Since then the registry has documented information
on over 800 patients. A 90% follow-up is to be maintained for patients diagnosed
and/or treated for cancer at our facility. To date the cancer registry has achieved a
follow-up rate of over 96%.
In 2009 a total of 241 new cases were identified. Of those, 211 (87.5%) were
analytic (diagnosed and /or treated at RWRH). The top five sites for RWRH are
Breast, Prostate, Lung, Colorectal and Bladder. The analytic growth trend for these
sites is shown below in Figure 1. These top 5 sites account for 63% of the total
analytic caseload seen at RWRH in 2009. From 2007 to 2009 the total case load for
RWRH has grown from 199 patients in 2007 to 241 patients in 2009, a 21% growth
over 2 years.
The Cancer Registry serves as a repository of information for physicians and
administrators to utilize when investigating equipment purchase, treatment
decisions, staffing issues, and overall program needs.
Cancer Conferences provide an opportunity for physicians to prospectively review
cases with the multidisciplinary team. In addition to the monthly general cancer
conferences, physicians on the middle peninsula can remotely attend the weekly
Breast Cancer Conference. Case conferences serve as important education offerings
for the physicians and other members of the healthcare team. In 2009 there
were 20 patients presented at Cancer Conference, 100% prospective discussion.
Multidisciplinary representation was at each conference.
Jennifer L. Brown, BS
Cancer Registry Supervisor
2 0 0 9 S TA T I S T I C S
1
Primary Site Sex
Class of Cases
Stage Distribution - Analytic Cases Only
M F Analytic Non-Analytic 0 I
II III IV Unk Blank/Inv
Cases %
ORAL CAVITY & PHARYNX
10
4.1%
7
3
10
0
0
4
0
2
1
3
0
Tongue 1
0.4%
1
0
1
0
0
0
0
1
0
0
0
Salivary Glands
2
0.8%
2
0
2
0
0
1
0
0
0
1
0
Floor of Mouth
1
0.4%
1
0
1
0
0
0
0
1
0
0
0
Nasopharynx
1
0.4%
0
1
1
0
0
0
0
1
0
0
0
Tonsil
4
1.7%
2
2
4
0
0
2
0
0
1
1
0
Oropharynx
1
0.4% 1
0
1
0
0
0
0
0
0
1
0
DIGESTIVE SYSTEM
42
17.4%
23 19
37
5
0
10
9
6
8
3
1
Esophagus
1
0.4%
0
1
1
0
0
0
0
0
1
0
0
Stomach
2
0.8%
2
0
2
0
0
1
0
1
0
0
0
Colon Excluding Rectum
19
7.9% 11 8
16
3
0
4
5
2
5
0
0
Rectum & Rectosigmoid
10
4.1%
2
8
8
2
0
4
1
1
0
1
1
Anus, Anal Canal & Anorectum
2
0.8%
2
0
2
0
0
0
1
0
0
1
0
Liver & Intrahepatic Bile Duct
2
0.8%
2
0
2
0
0
1
0
0
0
1
0
Pancreas
6
2.5%
4
2
6
0
0
0
2
2
2
0
0
RESPIRATORY SYSTEM
40
16.6%
29 11
36
4
1
9
4
7
15
0
0
Nasal Cavity, Middle Ear & Accessory Sinuses
2
0.8%
1
1
2
0
0
0
0
0
2
0
0
Larynx
10
4.1%
10 0
10
0
1
5
2
2
0
0
0
Lung & Bronchus
28
11.6%
18 10
24
4
0
4
2
5
13
0
0
SOFT TISSUE
1
0.4%
1
0
1
0
0
0
1
0
0
0
0
Soft Tissue (including Heart)
1
0.6%
1
0
1
0
0
0
1
0
0
0
0
SKIN EXCLUDING BASAL & SQUAMOUS
9
3.7%
7
2
7
2
0
1
2
2
1
1
0
Melanoma – Skin
7
2.9%
5
2
6
1
0
1
2
1
1
1
0
Other Nonepithelial Skin
2
0.8%
2
0
1
1
0
0
0
1
0
0
0
BREAST
52
21.6%
0 52
48
4
5
18 17 6
2
0
0
Breast
52
21.6%
0 52
48
4
5
18 17 6
2
0
0
2
Primary Site Sex
Class of Cases
Stage Distribution - Analytic Cases Only
M F Analytic Non-Analytic 0 I
II III IV Unk Blank/Inv
Cases %
FEMALE GENITAL SYSTEM
10
4.1%
0 10
9
1
0
3
0
3
1
0
2
Cervix Uteri
2
0.8%
0
2
2
0
0
1
0
1
0
0
0
Corpus & Uterus, NOS
6
2.5%
0
6
6
0
0
1
0
2
1
2
0
Ovary 1
0.4%
0
1
0
1
0
0
0
0
0
0
0
Vagina
1
0.4%
0
1
1
0
0
1
0
0
0
0
0
MALE GENITAL SYSTEM
36
14.9% 36 0
27
9
0
0
24 0
3
0
0
Prostate
36
14.9% 36 0
27
9
0
0
24 0
3
0
0
URINARY SYSTEM
12 5.0%
3
9
11
1
7
3
0
0
1
0
0
Urinary Bladder
10
4.1%
3
7
10
0
7
3
0
0
0
0
0
Kidney & Renal Pelvis
2
0.8%
0
2
1
1
0
0
0
0
1
0
0
BRAIN & OTHER NERVOUS SYSTEM
3
1.2%
2
1
3
0
0
0
0
0
0
0
3
Brain
3
1.2%
2
1
3
0
0
0
0
0
0
0
3
ENDOCRINE SYSTEM
4
1.7%
0
4
4
0
0
3
0
0
1
0
0
Thyroid
4
1.7%
0
4
4
0
0
3
0
0
1
0
0
LYMPHOMAS
7
2.9%
3
4
6
1
0
2
1
1
2
0
0
Non-Hodgkin Lymphoma
7
2.9%
3
4
6
1
0
2
1
1
2
0
0
MULTIPLE MYELOMA
2
0.8%
1
1
1
1
0
0
0
0
0
0
1
Multiple Myeloma
2
0.8%
1
1
1
1
0
0
0
0
0
0
1
LEUKEMIAS
4
1.7%
1
3
3
1
0
0
0
0
0
0
3
Lymphocytic Leukemia
3
1.2%
1
2
2
1
0
0
0
0
0
0
2
Myeloid & Monocytic Leukemia
1
0.4%
0
1
1
0
0
0
0
0
0
0
1
MESOTHELIOMA 2
0.8%
2
0
1
1
0
0
0
1
0
0
0
Mesothelioma
2
0.8%
2
0
1
1
0
0
0
1
0
0
0
MISCELLANEOUS
7
2.9%
1
6
7
0
0
0
0
0
0
0
7
Miscellaneous Sites
7
2.9%
1
6
7
0
0
0
0
0
0
0
7
241
211
30
13 53 58 28 35
7
17
Total
116 125
3
Cancer Program Annual Report 2010
The Riverside Walter Reed Hospital (RWRH) cancer program officially began in March 2004
with the opening of the Cancer Center. The Center is a freestanding facility on the Walter
Reed campus. It includes space for radiation oncology and medical oncology. Radiation
oncology includes a Siemens dual energy linear accelerator capable of treating patients
with IMRT and CT simulator as well as physician, physics, management and clerical office
space. There is also space for a nursing office and examination rooms as well as spacious
patient waiting area. The radiation oncology center is a accredited by the ACR/ASTRO
program, the premier accreditation body in the U.S.
James Wassum, MD
Radiation Oncology
Specialist
Medical Oncology includes a dedicated pharmacy, physician and nursing office space along
with multiple infusion stations including a private infusion room. Both oncology practices
have grown steadily since their opening. Patients served at the center come from a wide
area of rural Eastern Virginia including the Middle Peninsula and Northern Neck.
In 2007 RWRH established a tumor registry and active cancer committee. Processes
to seek accreditation by the American College of Surgeons Commission on Cancer are
currently underway.
Future plans look to expand the medical oncology floor space to allow for more treatment
space as well as numerous adjunctive services currently offered in the Newport News
and Williamsburg offices. In addition, increasing cooperation between the RWRH Cancer
Center and Riverside Tappahannock Hospital remains a goal for the Riverside Walter Reed
cancer program.
4
Figure 1: Analytic Growth Trend for Top 5 Sites
at RWRH 2007-2009
60
Number of Cases
50
40
Breast
Prostate
Colorectal
Lung
Bladder
30
20
10
0
2007
2008
2009
Year
Note: The graphs above (Figure 1) and below (Figure 2) illustrate growth trend in analytic caseload for Riverside Walter Reed
Note: The graphs above (Figure 1) and below (Figure 2) illustrate growth trend in anaylytic
caseload for Riverside Walter Reed Hospital. Analytic cases consist of those patients who were
diagnosed and /or treated at RWRH during the first course of treatment.
Figure 2: Analytic Cases: % Change 2008-2009
(Cases diagnosed and/or treated at RWRH)
-21.4% (-3 cases)
Leukemias
20.5% (+8 cases)
Lymphoma
28.6% (+10 cases)
Kidney
6.7% (+1 case)
Ovary
16.7% (+3 cases)
Pancreas
-31.3% (-10 cases)
Brain
44.1% (+15 cases)
Bladder
37.5% (+9 cases)
Uterus
25.8% (+8 cases)
Thyroid
54.8% (+17 cases)
Melanoma
Prostate
5.2% (+12 cases)
40.0% (+28 cases)
Colorectal
32.1% (+ 62 cases)
Lung
45.2% (+98 cases)
Breast
-40.0%
-30.0%
-20.0%
-10.0%
0.0%
10.0%
% Change
5
20.0%
30.0%
40.0%
50.0%
60.0%
Bladder Cancer at Riverside Walter Reed Hospital
Roger E. Schultz, MD
Hampton Roads
Urology
Urothelial carcinoma is cancer of the
lining of the bladder, ureter, or renal
pelvis. It is most commonly discovered
in the bladder and histologically appears
as transitional cell carcinoma in the
majority of cases. In the past year
doctors discovered 70,000 new cases and
there were around 15,000 deaths from
this disease. Men are affected three
times more commonly than women.
Smoking carries a fourfold increased
risk. People who work with industrial
cleansers, machinery, dyes, inks, paints,
and hairdressing supplies may be at
risk. People who have needed radiation
for pelvic cancers have an increased
risk of bladder cancer. Exposure to
Cyclophosphamide is yet another agent
that is a risk factor. There is not strong
evidence for a familial tendency to
develop urothelial cancer.
Figure 3: 2007-2009 Analytic Bladder Cancers
by Gender - RWRH Only
14
12
4
# of Cases
10
1
8
6
4
Female
Male
7
9
10
2
3
0
2007
2008
2009
Year
Figure 3 illustrates the distribution of cases among gender from
2007 to 2009. Generally there is a higher ratio of males to females;
however in 2009 more females were diagnosed with bladder cancer at
RWRH than males.
6
The classic presentation is an OLDER
MAN who SMOKES presenting with
GROSS PAINLESS HEMATURIA. Often
the patient will complain of urinary
urgency, frequency, and occasionally
dysuria. Alternatively, the patient may
have no symptoms and is identified solely
by microscopic hematuria on a routine
urinalysis. Sometimes bladder cancer
is incidentally noticed on a CAT scan
done for other reasons – reports might
indicate bladder wall thickening if not an
intravesical lesion.
The urologic work-up of microscopic or
gross hematuria includes a CT UROGRAM
to check the upper urinary tracts for
cancer, stones, or obstruction. It is
important to note that a CAT scan may
miss a small urothelial tumor in the
bladder. This is the reason that we must
also perform CYSTOSCOPY. With the
newest flexible endoscopes, this can
be easily done in the office. Urinary
cytology is helpful when positive. There
are several office based tumor screening
tests that look for proteins made by
these cancers (e.g., urinary NMP, BTA
stat). These are rapidly performed, office
based tests that suffer somewhat by false
positives from active infection or stones.
Like urinary cytology, they are helpful but
are not yet accurate enough to replace
cystoscopy. The Urovision FISH test
(fluorescence and in situ hybridization) is
a urinary test that looks at a molecular
level for cancer. It has been criticized for
being too sensitive a test. It may provide
an “anticipatory positive” - ie, suggestion
of a “cancer to come” even though the
urologist cannot find it by conventional
radiologic or endoscopic means.
The cystoscopic appearance of a classic
papillary transitional cell cancer is a true
“Aunt Minnie.” Once you’ve seen her, you
always remember the appearance. Less
commonly, bladder cancers may appear
as nodules, or raised, reddened areas that
are difficult to diagnose. ALL bladder
lesions require histologic confirmation. The
urologist will schedule an examination under
anesthesia (pelvic and rectal bimamual
exam to palpate for tumor fixation. He
then performs a transurethral resection of
the bladder tumor (TURBT). This is done
with regional or general anesthesia. In the
last few years, TURBT is usually followed by
the intravesical instillation of MITOMYCIN.
Papillary tumors often break up when
resected, and there is data to show that
immediate instillation of Mitomycin after
TURBT can reduce tumor “seeding” of other
areas of the bladder lining, thereby reducing
recurrence rates. After TURBT, the urologist
places a urethral catheter and instills 20-40cc
of Mitomycin in solution into the bladder. It is
drained one hour later in the recovery area.
The prognosis for recurrence is higher when
there are large tumors and/or multifocal
tumors. The overall prognosis is more
ominous if the tumor is nodular, as opposed to
papillary, and broad based. The pathologist
can tell us the histologic tumor type (typically
transitional cell carcinoma, less commonly
squamous carcinoma or adenocarcinoma),
the tumor grade, and the depth of tumor
invasion. Newer molecular markers may soon
be widely available to stratify those at high
risk for progressive disease. Fortunately, the
majority of tumors are superficial and easily
resectable lesions. About 50-70% are stage
Ta (at the epithelial surface), 20-30% are
T1 (invades lamina propria), 20-25% are T2
(muscle invasive). Thankfully, few are widely
metastatic at presentation.
Bladder cancers can recur, particularly if
there are large and/or multifocal at first
presentation. After TURBT patients are begun
on a routine cystoscopic surveillance program.
Selected circumstances may require the use
of intravesical agents to reduce recurrent
rates – especially patients with T1 tumors,
CIS, or frequent recurrences. The most
common agent employed is BCG, a weakened
tuberculosis strain that is instilled in the
bladder via catheterization once weekly for
6 weeks (“Induction therapy”). Patient must
retain the BCG for 2 hours if possible, then
eliminate it. The immune response can be
amplified by repeat exposure to intravesical
BCG (“Maintenance dosing”). They will
receive another 3 weeks of intravesical BCG
every 6 months out to about three years.
Some people cannot tolerate the dysuria,
urgency, and frequency that BCG may cause.
Symptoms may be ameliorated by reducing the
BCG concentration. Alternative intravesical
agents include Alpha 1 Interferon, Mitomycin,
Valrubucin, and Gemticibine.
Muscle invasive
bladder cancer (T2)
usually requires
open surgery. When
it involves the dome
of the bladder, it
may be amenable to
partial cystectomy
with wide margins
of resection. In
most cases, it will
require removing
the bladder/
prostate/regional
lymph nodes in men
and an anterior
exenteration in
women. The classic
urinary diversion
is a uretero-ileal
7
Figure 4: 2007-2009 First Course
Treatment for Analytic Bladder
Cancer at RWRH (n=34)
Surgery
88%
Surgery,
Chemotherapy
3%
Surgery,
Immunotherapy
9%
As seen in Figure 4 the predominant
method of treatment for bladder cancer
at RWRH is surgical intervention. From
2007 to 2009 there were no bladder
cases that received radiation therapy.
conduit (Bricker conduit). Ureters cannot be
brought up to the abdominal wall to drain
because they will stenose. A short segment of
ileum is interposed between the ureters and
the abdominal is wall because the ileal stoma
is less apt to obstruct. An ostomy appliance
can be applied to the UROSTOMY to collect
urine.
the abdominal wall. The tiny stoma is easily
concealed and the patient is dry between
catheterizations. Continent diversions avoid
the inconvenience of a collection bag on the
abdomen, but they are constructed at a big
cost – much longer surgery and recovery,
the risk of anastomotic leaks, loss of bowel
to create a neobladder (potential dumping
syndrome, B12 malabsorption, metabolic
acidosis). Some orthotopic neobladders will
leak at night during deep sleep.
In the last 15 years urologists have been
offering continent urinary diversions to
avoid the need for an external appliance.
These diversions involve the creation of a
neobladder, a reservoir instead of a conduit.
The neobladder is made from bowel (large,
small, or both) that is reconfigured to become
more spherical. It may be attached to the
native urethra so that the patient can void
spontaneously. This is called an orthotopic
neobladder. Alternatively, the patient may
require a urinary pouch (eg, Koch pouch,
Indina Pouch) that is accessed by self
catheterization through a small, flush stoma on
Patients who are too old or too ill for radical
cystectomy may be treated by a combination
of deep TURBT and chemotherapy/radiation.
Metastatic bladder cancer is treated with
chemotherapy and/or radiation. Urologists
must also remain involved because of
recurrent urinary bleeding from the principal
tumor that may require re-resection or
diversionary ureteral stents. The prognosis
with advanced disease is poor – most patients
live less than two years.
Figure 5: 2007 Comparison of Stage at Diagnosis
Bladder Cancer - RWRH vs. NCDB
50.0%
44.5%
45.0%
38.5%
% of Analytic Cases
40.0%
35.0%
30.8%
30.0%
25.0%
RWRH (n=13)
NCDB (n=44449)
23.0%
20.1%
20.0%
13.3%
15.0%
10.9%
10.0%
7.7%
0.0%
6.7%
4.6%
5.0%
0.0%
Stage 0
Stage I
Stage II
Stage III
Stage IV
0.0%
Unk
Stage at Diagnosis
The above graph is a comparison of stage at diagnosis for bladder cases seen
at RWRH in 2007 to those recorded in the 2007 National Cancer Data Base.
8
At first glance one may conclude that patients
at RWMC have higher stages of bladder cancer
at presentation than the national trend
(Figure 5). My opinion is that we have seen
too few cases to draw any firm conclusions.
I would like to offer several personal
observations about this population of patients:
Patients often delay their own diagnosis –
papillary tumors may bleed on Monday and
stop bleeding on Tuesday. Patients get a
false sense of security once the bleeding
stops. Others may have noted months of
Nancy McKinney, MD, Chair
Melvin Schursky, MD Cancer Liaison Physician
James Wassum, MD
Ronald Haggerty, MD
Warren Helwig, MD
Val Curran, MD
David Schengber, MD
Elizabeth Martin
Keith Gregory
Paula Burcher
Beverly Voglewede
Patricia Emerson
Joe Hughes
Sue Moffitt
Suzanne Riley
Angie Healy
Fran Holcomb
Jennifer Brown
Carol Richards
Doctors occasionally delay the diagnosis of
bladder cancer in women. They may treat
women with hematuria for presumed cystitis,
when in fact, their urine cultures show no
growth. If a patient presents with urinary
bleeding and a negative culture, she should be
referred for urologic evaluation.
Medical Oncology
General Surgery
Radiation Oncology
Hospitalist
Pathology
Radiology
Radiology
VP Riverside Tappahannock/Walter Reed Hospital
Service Line Administrator, Oncology
Administrative Director, Radiology
Director, Radiation Oncology Services
Nurse Manager, Outpatient Infusion Center
Director, Performance Improvement
Nurse Manager, Riverside Walter Reed Hospice
Director, Radiology
Director, Public Relations
Cancer Education/Outreach Nurse
Cancer Registry Supervisor
Cancer Registrar
For additional information regarding Riverside Cancer Services,
please call (800) 520-7006.
For comments or questions regarding this Annual Report or the
Cancer Registry, please call (757) 594-3054.
2010 ONCOLOGY
COMMITTEE MEMBERS
episodic painless hematuria before they tell
a physician, possibly out of ignorance or fear.
We could do a better job of educating people
about bladder cancer symptoms and continue
efforts to stop people from smoking.
7544 Medical Drive
Gloucester, Virginia 23061
(804) 693-4900
http://www.riversideonline.com/rwrh/rmpcc.cfm