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Memorial Hermann Cancer Services Annual Report of Data

VIEWS: 146 PAGES: 40

									Memorial Hermann Cancer Services 2003 Annual Report of 2002 Data




                                                      Cancer
                                                      in the
                                                      Community




                         FOR YOUR WHOLE LIFE
Table of Contents



OVERVIEW
1    Cancer Care at Memorial Hermann: Message from the President
3    Care and Treatment of Brain Cancer at Memorial Hermann
     William Gormley, M.D. Neurosurgery
     Clive Shkedy, M.D. Radiation Oncology
     Luis T. Campos, M.D. Medical Oncology
8    Treatment of Cervical Cancer at Memorial Hermann
     Terri Pustilnik, M.D. Gynecological Oncology
     Arthur Hamberger, M.D. Radiation Oncology
     T.F. Tenczynski, M.D. Medical Oncology

12 Diagnosing Cancer at Memorial Hermann
14 Cancer Treatment Options
15 Research/Institutional Review
15 Ancillary Services


MEMORIAL HERMANN CANCER SERVICES PROGRAM REPORTS
18   Memorial Hermann Healthcare System
20   Memorial Hermann Hospital
23   Memorial Hermann Katy Hospital
26   Memorial Hermann Memorial City Hospital
29   Memorial Hermann Northwest Hospital
32   Memorial Hermann Southwest Hospital
35 Glossary of Terms
36 Information
Cancer Care at Memorial Hermann



Cancer can affect anyone: young or old, rich or poor, male or female, people of any race or ethnic group.
As such, it not only is a formidable foe, but it also is a uniting force as entities within the community
collaborate to prevent, diagnose and treat the disease.
   Memorial Hermann Healthcare System plays a leadership role in this effort. At our hospitals, located
throughout the Houston metropolitan area, hundreds of physicians and specialists in a multitude of
disciplines are working to improve the survival rates and quality of life of people with cancer. With our
extensive knowledge and experience and our access to state-of-the-art technologies, we provide compre-
hensive, effective care at facilities close to patients’ homes and families.
   In this report, we focus on two forms of cancer, brain and cervical. Our purpose here is to provide
information about these diverse conditions to patients and their families as well as to update health-care
practitioners on activities underway within Memorial Hermann Healthcare System to improve diagnosis
and treatment.
   At Memorial Hermann, we’re fighting the war against cancer on two fronts — within the physical
boundaries of our facilities and through programs that reach out into the community. The success of this
dual effort can be seen in the growing number of people who are living longer with cancer or who have
had cancer but are now disease-free.




                                                     Dan J. Wolterman
                                                     President
                                                     Memorial Hermann Healthcare System
Care and Treatment of Brain Cancer at Memorial Hermann

        rimary brain tumors compose only 2 percent of all adult             been shown to have a more favorable course and are more respon-         William Gormley, M.D.
P       cancers. More than 60 percent of primary brain tumors are
malignant glioma. Glioblastoma Multiforme (GBM), World Health
                                                                            sive to chemotherapy, in particular, when they show certain
                                                                            chromosomal abnormalities.
                                                                                                                                                    Neurosurgery

Organization (WHO) grade 4, is the most common and aggressive                                                                                       Clive Shkedy, M.D.
form of diffuse fibrillary astrocytomas. Glioblastoma Multiforme            MENINGIOMAS                                                             Radiation Oncology
may develop de novo or much less frequently as it progresses over           Meningiomas are generally benign tumors arising from the arach-
the years through malignant transformation from lower-grade astro-          noid meninges. They are generally managed by surgical resection.        Luis T. Campos, M.D.
cytomas. In such cases it is often referred to as secondary                 These tumors are not easily accessible; therefore, surgery may result   Medical Oncology
glioblastoma. Although there are no specific histological or clinical       in functional deficit, incomplete resection of the tumors. These
differences, these tumors have a defined genetic profile, which may         tumors and those meningiomas that have malignant features can be
allow identification of new and more specific treatment targets.            treated by external beam radiation or Gamma Knife radiosurgery.
    Low-grade astrocytomas, oligodendrogliomas and oligoastrocy-
tomas are less common than Glioblastoma Multiforme and carry                SURGERY
better prognoses than the diffuse astrocytomas. Patients with these         No other modality can reduce tumor bulk as quickly as surgery.
tumors (WHO grade II) may have a mean survival time of about                There have been many advances in imaging, computerized naviga-
10 years. In addition, oligodendrogial tumors appear to be more             tion, pharmacologic agents for brain edema, neuroanesthesia and
chemo-sensitive when compared with diffuse astrocytomas. These              surgical magnification. Illumination and instrumentation such as
tumors, nonetheless, are infiltrative and have a marked potential for       ultrasonic aspirators have made operative approaches to tumors pos-
malignant progression and may transition from WHO grade II to               sible and reasonably safe. Brain tumor surgery, when resection is
III. Anaplastic astrocytomas (WHO grade III) are marked by an               possible, is a curative form of treatment. When surgical cure is not
increase in malignant behavior. They have a number of molecular             possible, as in most gliomas, tumor debulking and consequent
abnormalities induced by chromosomal aberrations. The loss of               decompression of the brain is the secondary goal. When possible,
chromosome 9p occurs in 50 percent of the anaplastic astrocytomas,          surgery should be the first therapeutic maneuver.
and the loss of chromosome 10 is a frequent finding in                          For tumors that appear to be located in critical motor or lan-
Glioblastoma Multiforme. These losses may activate kinases that             guage areas, functional MRI is becoming an important preoperative
require cell proliferation. Therefore, it is likely that a tumor suppres-   screening test. This determines the feasibility of the surgery with
sor gene resides on this chromosome that carries important genes as         intraoperative electrophysiologic mapping to plan a safe approach to
the DBMT’1 gene. One of the hallmarks of Glioblastoma                       an intra-axial tumor. Magentoencephalography offers similar bene-
Multiforme is microvascular proliferation. A host of angiogenic             fits in a dedicated device. Tumor removal is usually done with
growth factors and their receptors are found in Glioblastoma                grasping instruments, bipolar coagulation and suction. The removal
Multiforme. These findings will become very important in the treat-         of firm, adherent or calcified tumor tissue can be quite difficult.
ment of these tumors with antiangiogenic drugs and tyrosine kinase          However, resection can be achieved by the use of the Cavitron ultra-
receptor inhibitors, such as VEGF (Vascular Endothelial Growth              sonic aspirator (CUSA), which ultrasonically disrupts the tumor at
Factor) receptor inhibitors, and Gleevec, which is already available        its tip and is quickly aspirated. Also, the CO2 laser can vaporize
for the treatment of other tumors. Unfortunately, Gleevac has not           tumor tissue with a hands-off technique.
demonstrated activity in Glioblastoma Multiforme.                               In the rare situation in which brain swelling is worrisome at the
    In contrast, anaplastic oligodendrogliomas (WHO grade 3) have           time of closure, a catheter is left in the subdural space to measure

                                                                                                                                                                            3
                     FIGURE I:
                     2002 BRAIN CANCER
                     PATIENT DEMOGRAPHICS
                                                                                                 the intracranial pressure. All patients are monitored in the intensive
                     AT MHHS FACILITIES
                                                                                                 care unit for at least one night following surgery. A MRI scan is
                                                                                                 done within 48 hours to evaluate the success of the tumor resection.
                                                                                                 Serum electrolyte levels and osmolality are measured frequently in
                      Total Patients                     95                                      the postoperative period. This is done to ensure that the patient is
                      Race                                                                       relatively dehydrated to prevent cerebral edema through the first
                      White                         47 (49%)                                     several post-operative days and to detect the possible onset of inap-
                      Hispanic                      23 (24%)                                     propriate secretion of antidiuretic hormone or diabetes insipidus.
                      Black                         15 (15%)
                      Asian                           2 (2%)                                     STEREOTACTIC TUMOR BIOPSY
                      Other                           8 (8%)                                     For intrinsic tumors of the deep midline (e.g., pontine or corpus
                      Gender                                                                     callosum gliomas), deep tumors of the dominant hemisphere or dif-
                      Female                        55 (58%)                                     fuse non-focal tumors, surgical resection is not practical. In these
                      Male                          40 (42%)                                     situations, needle biopsy for diagnosis is essential. There is no longer
                                                                                                 any reason to perform a full craniotomy only for the purpose of
                                                                                                 biopsy. Tissue can be obtained through a needle directly by hand
                                                                                                 through a burr hole under CT or MRI scan guidance or a needle
                                  1 (1%)
                                                                                                 directly by many devices that incorporate ultrasound images.
                                           5 (5%)
                        6 (6%)
                                                        5 (5%)                                   RADIATION THERAPY
                                                                                                 Most primary CNS neoplasms are unifocal. Substantial amounts of
                                                                 5 (5%)
          12 (13%)                                                                               normal tissue must often be irradiated in the typical patient receiv-
                                                                                     AGE AT
                                                                                                 ing high-dose radiation with curative intent because of the need to
                                                                                     DIAGNOSIS   treat not only the tumor, but also the surrounding edema with a
                                                                                     10-19       margin reflecting the infiltrative nature of these tumors.
                                                                                     20-29

                                                                                     30-39       GAMMA KNIFE
                                                                          18 (19%)   40-49       Gamma Knife radiosurgery is a technique in which 201 cobalt radi-
                                                                                     50-59       ation sources intersect at one focal point, thereby allowing the
                                                                                     60-69       delivery of a single high dose of irradiation to a small and critically
                                                                                     70-79       located intracranial volume through the intact skull.
    20 (21%)
                                                                                     80-89

                                                                                     90-99       CHEMOTHERAPY
                                                                                                 Despite adequate surgical therapy, malignant gliomas recur in virtu-
                                                                                                 ally all patients and usually within 2 centimeters of the resection
                                                                                                 margin. In patients with longer survival, this dissemination through-
                                           23 (24%)                                              out the central nervous system is observed, suggesting that the

4
FIGURE II:                                                  FIGURE III:
DISTRIBUTION BY HISTOLOGY                                   DISTRIBUTION OF TREATMENT
                                                            TOTAL PATIENTS = 95




 Malignant Tumors
                                                                          10
 Glioblastoma                             19
 Astrocytoma                               6                1
                                                        1
 Malignant meninges                        6
 Oligodendroglioma                         5        5
 Glioma                                    2
 Mixed glioma                              2
 Medulloblastoma                           2
 Gliosarcoma                               1
 Astroblastoma                             1
 Meningeal sarcomatosis                    1
 Teratoma with malignant transformation    1   18

 Gliomatosis cerebri                       1
 Papillary ependymoma                      1
 Borderline Malignant Tumors                                                                                   60
 Craniopharyngioma                         3
 Hemangioblastoma                          2
 Benign Tumors
 Meningiomas                              34
 Dysembryoplastic neuroepithelial          3
 Transitional meningioma                   2
 Psammomatous meningioma                   1                    Surgery

 Ganglioneuroma                            1                    Gamma Knife

 Meningothelial meningioma                 1                    Combo (surgery with Gamma Knife)

 TOTAL PATIENTS                           95                    Combo (surgery with whole brain XRT)

                                                                Combo (surgery with chemo)

                                                                No treatment (pt exp, not recommended, etc.)




                                                                                                                    5
                                                                                                                          diseases affect the whole brain parenchyma.
                                                                                                                              The standard of care is radiation therapy following surgery or
                                            FIGURE IV:                                                                    biopsy. The brain is considered a pharmacologic sanctuary due to
                                            DISTRIBUTION OF SITES / LOBES
                                                                                                                          the blood-brain barrier. The antineoplastic drugs should be
                                            TOTAL PATIENTS = 95
                                                                                                                          lipophilic to cross such a barrier. The nitrosoureas are the most
                                                                                                                          commonly used drugs. Temozolimide, a new alkylating chemothera-
                           Cerebral meninges                                                                              py agent, has come to play an important role, since it readily crosses
                                                                                          Meninges, NOS
                                                                                                                          the brain barrier. It is administered orally, allowing prolonged and
                                                                                                                          continuous schedules, although they have not been fully studied yet.
                                                                                                                          Irinotecan and topotecan may play a limited role, since many
                                                                                                                          patients are on anticonvulsant drugs that interfere with their action.
                                                                                                                          Intralesional deposits of biodegradable BCNU wafers have not
           Brain, NOS
                                                                                                                          demonstrated meaningful survival benefit.
                                                                                                                              Chemotherapy is reserved for patients with recurrent disease and
                                                                                                                          as adjuvant therapy for selected patients. None of the randomized
                                                                                                                          trials were able to demonstrate a significant survival advantage with
                                                                                                           Frontal lobe   adjuvant chemotherapy. Young patients and patients with WHO
                                                                                                                          grade 3 astrocytomas may benefit with adjuvant chemotherapy.
                                                                                                                          However, a large prospective randomized trial has demonstrated no
    Overlapping lesion
                                                                                                                          advantage with the procarbazine, CCNU and vincristine combina-
                                                                                                                          tion. There are several possible explanations:
                                                                                                                          • Drugs not reaching the target.
                                                                                                                          • Drugs not sufficiently active.
                  Brain stem
                                                                                                                          • Rapid development of resistance by the tumor.
                         Cerebellum                                                        Temporal lobe
                                                                                                                          BRAIN BARRIER
                                                                                                                          Nitrosoureas are nonionized and lipophilic molecules that readily
                                  Ventricle lobe
                                                                                                                          cross the blood-brain barrier. They were the most commonly used
                                                   Occipital lobe         Parietal lobe
                                                                                                                          agents for malignant glioma. BCNU (carmustine) is frequently sub-
                                                                                                                          stituted by CCNU (lomustine), which is given orally and carries less
                                                                                                                          pulmonary toxicity. Fotemustine is an investigational agent with
                                                               Meninges                                                   some activity. Procarbazine is an alkylating agent, which is also given
                                                               Brain                                                      orally and requires hepatic activation.
                                                                                                                              Temozolamide is a novel imidazotetrazine derivative that acts as
                                                                                                                          an alkylating agent. It is administered orally and has 100-percent
                                                                                                                          bioavailability. Myelosuppression with delayed thrombocytopenia is
                                                                                                                          the main side effect. The drug is given in daily dose for five days,

6
                                                                                                               FIGURE V:
                                                                                                               FIVE-YEAR SURVIVAL STATISTICS
                                                                                                               TOTAL PATIENTS = 95

every four to six weeks. More recently prolonged and continuous
administration schedules are being used.                                                                 100
   Targeted therapies which act by inhibiting signaling pathways
that regulate the cell cycle are being sought. Among the new drugs                                        90
is Gleevec. Other drugs are targeting inhibitors of angiogenesis that
could be combined with radiotherapy and temozolamide.                                                     80

OUR EXPERIENCE                                                                                            70
Ninety-five patients with primary tumors of the brain were seen at




                                                                                  PER CENT S UR VIVING
                                                                                                          60
Memorial Hermann Hospital in 2002. Thirty-three patients were
diagnosed with meningiomas and 62 parenchyma tumors. When the
                                                                                                          50
tumors were classified by their grade of malignancy, 42 were benign,
five were borderline and 48 were malignant (see Figure II). The dis-                                      40
tribution of brain tumors by age and gender was 40 male and 55
female (see Figure I). The race distribution is also shown in Figure I.                                   30
The treatment was equally distributed regardless of race or age.
Seventy-eight patients were treated with one modality of treatment;                                       20
the most common treatment was surgery. This figure may not repre-
sent those patients who received external beam radiotherapy                                               10
post-surgically in other institutions. Combination regimens were
given to seven patients, and 10 patients received no treatment.                                            0

Nevertheless, of the 18 patients with Glioblastoma Multiforme, 11                                                              12     24                  36     48   60
had surgery; two, Gamma Knife; one, surgery and Gamma Knife;                                                                         N U M BE R O F M O N TH S

one, surgery and whole brain radiation; and one, surgery with whole
brain radiation and chemotherapy.                                                                                                        MHHS

                                                                                                                                         SEER
FIVE-YEAR STATISTICS
The relative five-year survival of patients with cerebral tumors was
compared with the Surveillance, Epidemiology and End Results              the evidence by type of tumor has not been entered into account.
(SEER) that represent the national average. Unfortunately, the            Survival data at the Memorial Hermann Hospital were closely mon-
SEER does not break down the distribution by type of tumor,               itored, with the Cancer Registry contacting and verifying the
aggressive versus low-grade astrocytomas. Nevertheless, the distribu-     patients’ vital status.
tion by age and race is similar to the Memorial Hermann Hospital              In summary, the treatment and survival for brain cancer are very
experience, but the incidence of these tumors was predominant in          similar to national data. There are no recommendations for changes
male patients at Memorial Hermann Hospital. When the relative             to clinical care or documentation at this time. It is important to
survival was compared with the SEER data, the Memorial Hermann            continue to promptly evaluate patients and enroll them in clinical
five-year survival time was slightly higher than the SEER, although       trials as available. ❏

                                                                                                                                                                           7
                                       Treatment of Cervical Cancer at Memorial Hermann

  Terri Pustilnik, M.D.                        he incidence of invasive cervical cancer has fortunately             help to determine the “stage” or extent of the patient’s cancer.
  Gynecological Oncology               T       become less common in the United States, formerly repre-
                                       senting the most likely cause of death in child-bearing women. It is
                                                                                                                    Cervical cancer prognosis is related to staging. Stage I carries the
                                                                                                                    best prognosis and stage IV the worst prognosis. Stage I disease is
  Arthur Hamberger, M.D.
                                       estimated that in 2002, there will be 13,000 new cases of cervical           limited to the cervix; stage II involves the tissue nearby, such as the
  Radiation Oncology
                                       cancer diagnosed in this country with 4,100 deaths from this                 parametrium and/or upper vagina; stage III involves the pelvic side-
  T.F. Tenczynski, M.D.                disease1. The main reason for the decline is the long-term adoption          wall or lower vagina; and stage IV cancer has spread to distant sites,
  Medical Oncology                     of Papanicolaou screening and, more recently, the use of Human               such as lung or colon2. Roughly 90 percent of cervical cancers are
                                       Papilloma Virus (HPV) testing. These techniques help to identify             termed squamous cell, whereas 10 percent are called adenocarcino-
                                       women with preinvasive disease (or cervical dysplasia) and thus pre-         ma. The remainder is composed of other more unusual and rare
                                       vent cervical cancer from developing by treating the precancerous            types that may require complex treatment managements.
                                       lesion. Although still experimental, there is promise that a vaccine
                                       for this disease may be developed, which may lead to the eradication         TREATMENT
                                       of cervical cancer altogether.                                               Treatment for cervical cancer can be divided into three categories:
                                                                                                                    surgery, radiation therapy and chemotherapy. Early stages can be
  FIGURE I:                                                                 DIAGNOSIS                               managed with either surgery or radiation therapy or radiation thera-
  CERVICAL CANCER
  AGE AT DIAGNOSIS
                                                                            Most women are initially diagnosed      py along with chemotherapy. More advanced stages are best treated
  AGE AT DIAGNOSIS N = 33
                                                                            in their early forties. Consequently,   with radiation therapy and chemotherapy. Studies have shown that
                                                                            entire families may be intimately       radiation therapy along with chemotherapy can significantly
                            80+ (3%)   20-29 (3%)
                                                                            affected, since many women are still    improve survival in patients with large tumors or unfavorable char-
                                                                            in the process of raising young chil-   acteristics, such as spread to lymph nodes.
                                                                            dren. Early symptoms include               Surgery for cervical cancer usually consists of a radical hysterecto-
             70-79 (18%)                                                    vaginal spotting, bleeding after        my. This operation differs from a routine hysterectomy in that, in
                                                              30-39 (24%)   intercourse, vaginal discharge or       addition to removing the cervix and uterus, the tissue surrounding
                                                                            pelvic pain. Alternatively, there may   the cervix and the pelvic lymph nodes is removed as well. This helps
                                                                            be no symptoms at all, but the dis-     to determine if there has been microscopic spread to the lymph
                                                                            ease may be revealed during an          nodes. Since this is a more radical procedure, the blood loss is typi-
                                                                            annual gynecologic exam or by           cally more and the surgery longer, and the bladder may take longer
                                                                            pap smear.                              to recover its normal function. Other complications from surgery
60-69 (9%)                                                                                                          can include the formation of blood clots, vaginal shortening, abnor-
                                                                            STAGE                                   mal connections or fistulas, bladder dysfunction and, more
                                                                            Once cervical cancer is diagnosed,      uncommonly, rectal dysfunction or small bowel obstruction4.
                                                                            a pelvic exam along with a CT scan      Fortunately, the ovaries can often be left in place so that “early”
      50-59 (6%)                                                            of the abdomen and pelvis and           menopause and its associated symptoms can be avoided in the
                                                                            chest X-ray are performed. These        younger patient.
                                                                            studies help to determine if there         In February 1999, the National Cancer Institute issued a clinical
                                                                            has been spread of the cancer           alert to all physicians who treat invasive cervical cancer3. This state-
                                                40-49 (36%)                 beyond the cervix and therefore         ment discussed five separate clinical trials comparing the results of

  8
treating cervical cancer patients with radiation therapy alone versus      prognosis. However, our ability to detect this is limited to surgical
radiation therapy and concomitant chemotherapy with cisplatin              exploration or to imaging studies such as CT scans, which may not
alone or with a cisplatin-containing combination of drugs. Two of          be capable of detecting microscopic metastases. The addition of
the studies compared cisplatin-containing regimens with non-cis-           chemotherapy concomitantly given with radiation has led to an
platin chemotherapies. All of the studies demonstrated significantly       improvement in the overall prognosis for patients with more
improved disease-free and overall survivals by 30-50 percent for the       advanced cervical cancer.
cisplatin-treated groups of patients. These findings changed the
standard of care for invasive cervical cancer, showing the superiority     RECURRENT DISEASE
of radiation plus cisplatin chemotherapy compared to radiation             If cervical cancer recurs, it will usually do so within the first two
alone. Consequently, radiation therapy given with cisplatin has            years. Therefore, close follow-up evaluation is recommended during
become the standard of care.                                               this time. Symptoms may include persistent back or abdomino-
   Patients receive radiation treatment with a combination of exter-       pelvic pain or bleeding. The main sites of recurrent cancer are
nal beam and intracavitary irradiation. The external beam is               distant, such as lung, or the pelvic wall or central pelvis.
generally delivered to the pelvic area to treat not only the primary       Unfortunately, the prognosis for recurrent cancer remains poor.
tumor in the cervix, but also the regional lymph nodes that are at         Treatment options are dependent on the location of the disease.
risk or involved by cancer. A relatively uniform dose is delivered to      Central pelvic recurrences may be treated with the radical surgery of
these structures over a period of four to six weeks. Side effects          pelvic exenteration. In this operation, the bladder, lowest colon and
include some degree of fatigue as well as bowel and bladder irrita-        pelvic structures are completely removed, and a new bladder is cre-
tion and moderate irritation of the skin. Diarrhea and urinary             ated, along with a colostomy. For recurrences beyond the central
symptoms can generally be well-controlled with simple medications.         pelvis, chemotherapy and sometimes radiation therapy can be used
When treatment involves chemotherapy, some of the side effects             to help improve symptoms. Although occasionally a patient can be
may be more intense. Intracavitary irradiation is administered using       cured with this intervention, it remains rare.
radioactive isotopes that are inserted into special applicators that
have been placed in the uterine cavity and the vagina. This treat-         OUR EXPERIENCE
ment is delivered in the hospital and may take up to three days to         During 2002, there were 33 patients treated for cervical cancer at
administer. It allows for the delivery of a relatively high dose to the    four of the community Memorial Hermann Healthcare facilities.
cancer and a much lower dose to the surrounding normal tissues.            These facilities include the Memorial Hermann Katy, Memorial
Intracavitary irradiation is generally given following external beam       City, Northwest and Southwest hospitals. Most women (60 percent)
radiation therapy when the tumor has reduced in size, allowing clos-       were between the ages of 30 and 49. Twelve (36 percent) were age
er placement of the radioactive sources to the tumor.                      40 and 49, while eight (24 percent) were age 30-39. Women in
                                                                           their seventies represented 18 percent of the group, while just 9 per-
PROGNOSIS                                                                  cent were in their sixties. (Figure I)
In early stage disease, the smaller the size of the cervical cancer and       Fifty-five percent were Caucasian, while 27 percent were African-
cervix, the better the prognosis. Five-year survival for stage I is over   American. The majority of patients (73 percent) were diagnosed
80 percent. Alternatively, spread beyond the cervix leads to a poorer      with early-stage disease, with 52 percent having stage I and 21 per-
prognosis. Five-year survival for stage IV is less than 15 percent.        cent having stage II. There were six patients with advanced cervical
Lymph node involvement is an important factor in determining               cancer, most of whom were in the category of stage III (13 percent).

                                                                                                                                                    9
FIGURE II:
CERVICAL CANCER, FIRST COURSE OF TREATMENT BY AJCC STAGE
                                                                                                                              Just over 10 percent of patients were unstaged. When compared to
                                                                                                                              National Cancer Data Base (NCDB) data, this distribution reflects
 TREATMENT                              STAGE I   STAGE II    STAGE III   STAGE IV   UNSTAGED          TOTAL    %             diagnosis at early-stage disease (stage I and II) at our facilities to be
 Radiation                                 1         0           1           0           0               2     (6.1)          slightly higher.
 Surgery                                   7         0           0           0           3              10   (30.3)               As expected, the treatment for stage I cervical cancer was near-
 Surg, Rad                                 1         0           0           0           0               1     (3.0)          equally distributed between surgery and radiation therapy (plus or
 Chemo, Rad                                5         6           2           1           0              14   (42.4)           minus chemotherapy). Eight patients underwent surgical resection,
 Srg, Rad, Chemo                           3         1           1           0           0               5   (15.1)           while five patients received radiation therapy concomitantly with
 No Treatment                              0         0           0           0           1               1     (3.0)          chemotherapy and one patient received radiation therapy alone.
 TOTAL                                    17         7           4           1           4              33 (99.9%)            Three patients with stage I disease had a combination of all three
                                                                                                                              therapies. All patients with stage II cervical cancer received treat-
                                                                                                                              ment that included radiation therapy and chemotherapy, and one
                                                                                                                              also had a hysterectomy. Of the 19 patients system-wide who
FIGURE III:                                                                                                                   received chemotherapy as part of their initial treatment of cervical
CERVICAL CANCER, FIVE-YEAR SURVIVAL BY AJCC STAGE
                                                                                                                              cancer, all received cisplatin-based treatment. Most patients with
                                                                                                                              advanced disease did not have primary surgical resection (Figure II).
                                  100                                                                                             Overall five-year survival rates of patients with cervical cancer at
                                                                                                                              Memorial Hermann Healthcare System facilities for the years 1994
                                   90                                                                                         to 1997 (n=154) were roughly similar. When combined, the overall
                                                                                              STAG E I                        five-year survival is 66 percent. The national survival rate for
                                   80                                                                                         patients with stages I-IV cervical cancer at comparable community
                                                                                                                              facilities nationwide, as reported by the NCDB, is approximately
                                   70
                                                                                                                              59 percent5 (Figure III). ❏
     P ER CE NT SU R V I V I NG




                                   60
                                                                                                                              NOTES

                                   50                                                         STAG E I I                      1 American Cancer Society 2002
                                                                                                                              2 SGO Handbook, 2nd Edition, January 1997
                                   40                                                                                         3 National Cancer Institute, Clinical Announcement, February 1999
                                                                                              STAG E I I I
                                                                                                                              4 Morrow, C.P., and Curtin, J.P., Gynecologic Cancer Surgery 1996,
                                   30                                                                                           Churchill Livingston Inc.
                                                                                                                              5 National Cancer Data Base, Commission on Cancer, Survival Reports 2003, v1.3
                                   20


                                   10
                                                                                                                   NCDB 1994-1995 N = 6,365
                                                                                              STAG E I V
                                                                                                                       MHHS 1994-1997 N = 147
                                    0
                                           12        24           36         48          60
                                                    NUMB ER OF MONTHS

10
Memorial Hermann
Cancer Services




                  11
     Diagnosing Cancer at Memorial Hermann

     RADIOLOGY                                                               NUCLEAR IMAGING
     The Memorial Hermann Radiology departments play a critical role         Another potential diagnostic tool is Positron Emission Tomography
     in the diagnosis and staging of all types of cancer. Memorial           (PET). At Memorial Hermann Hospital, physicians trained in
     Hermann radiologists employ sophisticated, computerized imaging         nuclear medicine use PET scans to create a picture of the inside of
     studies, sonographic modalities and interventional procedures as        the body by recording signals emitted by radio-tracers as they travel
     well as standard radiographic techniques.                               throughout the body and accumulate in the organs. A computer
         While standard X-ray remains important in diagnosing tumors of      reassembles the signals into images that reflect the abnormal glucose
     the chest and bone, computed tomography (CT) provides direct            accumulation in tumors. The role of PET scans in diagnosing lym-
     imaging and differentiation of soft tissue structures, such as liver,   phoma, lung cancer and other cancers is being actively investigated
     lung tissue and fat. CT scans can reveal the presence, size, spatial    at Memorial Hermann Hospital. Studies have shown PET to be a
     location and extent of tumors and are used for planning radiograph-     useful diagnostic tool, and further trials are evaluating its prognostic
     ic cancer treatment, for following the course of cancer treatment       value.
     and for determining how the tumor is responding.
         New fluoroscopic CT procedures allow radiologists to better         PATHOLOGY
     guide tissue biopsies and facilitate minimally invasive surgery or      The Pathology and Laboratory Medicine department includes a
     microtherapy. They allow physicians to monitor the path of needles      large number of specialists in all areas of anatomic and clinical
     or surgical instruments as they are inserted, which eliminates the      pathology. Particular expertise exists in transfusion medicine,
     slow “slice-by-slice process” and allows CT-guided interventional       hematopathology, coagulation, general and special chemistry, toxi-
     procedures to be streamlined significantly.                             cology, microbiology, mycology, virology, autoimmune testing,
         The high tissue contrast offered by magnetic resonance imaging      serology, cytopathology, pulmonary pathology, liver pathology, gyne-
     (MRI) augments the evaluation of many types of tumors. In addi-         cologic pathology, pediatric pathology, renal pathology,
     tion, radioisotopic bone scanning is essential to the early detection   neuropathology, cardiovascular pathology, ocular pathology, der-
     of metastatic bone disease and is used to monitor the response to       matopathology, muscle and nerve pathology and molecular
     therapy.                                                                pathology. These specialists have extensive experience not only in
         Advances in high-resolution diagnostic ultrasound have improved     the diagnosis of cancer, but also in the evaluation and response to
     its accuracy and reliability in aiding the diagnosis of many abdomi-    other medical problems that cancer patients can develop, including
     nal tumors. The use of automated core needles has increased             the detection and diagnosis of infections, effects of treatment and
     diagnostic accuracy to greater than 90 percent for percutaneous nee-    support of blood product needs.
     dle biopsies.
         Stereotactic needle biopsy is also used to diagnose nonpalpable     Anatomic Pathology
     and calcified breast lesions; two X-ray films of the area are pro-      Anatomic pathology services include surgical pathology and
     duced, offset from each other by a predetermined number of              cytopathology, services that evaluate the majority of biopsies and
     degrees. Using information from the X-ray, a computer calculates        other procedures done for diagnosis of cancer. In surgical pathology
     the exact site of the lesion and positions the needle precisely to be   and cytopathology, pathologists apply a comprehensive range of
     inserted into the lesion to extract tissue for histologic study.        morphologic, immunohistochemical and molecular tests to establish
         Memorial Hermann Radiology departments are accredited by the        a diagnosis of cancer. The histology laboratory supports the diagnos-
     American College of Radiology for complying with requirements set       tic work of pathologists, and additional specialized tests are provided
     forth for film screen mammography.                                      by separate state-of-the-art immunohistochemistry, flow cytometry,
12
molecular biology and electron microscopy laboratories. By bringing
specialized diagnostic expertise, Memorial Hermann Hospital
pathologists offer added value to the evaluation of cancer patients.

Clinical Pathology
The clinical pathology laboratories assist in the diagnosis of cancer
and follow-up of patients with cancer. The laboratories perform
numerous cancer-screening tests on blood samples, including PSA,
CEA, beta HCG, AFP and CA125. Some of these tests are able to
detect certain types of cancer before they are recognized clinically. In
some cases, these tests are also used to evaluate patients for recur-
rence or metastasis of cancer. In addition to performing cancer
marker analysis, the clinical laboratory performs the routine blood
counts, chemistries, urinalyses, coagulation testing and testing for
infectious diseases that can be very important in the support of the
cancer patient throughout treatment.

GAMMA KNIFE RADIOSURGERY
Memorial Hermann Hospital is the only health-care facility in
Houston and one of only about 80 nationwide that offer Gamma               techniques. When lymphedema is diagnosed promptly and com-
Knife radiation therapy (radiosurgery), an alternative to convention-      plete decongestive therapy is begun early, patients can enjoy
al brain surgery for patients with small to mid-sized brain tumors,        productive lives with few complications and little or no lifestyle
blood vessel abnormalities and pain from the trigeminal neuralgia, a       restriction. Memorial Hermann Hospital offers the only compre-
disorder of the facial nerves. During this procedure, 201 high-inten-      hensive lymphedema management program in Houston and also
sity beams of ionizing gamma rays are focused on a specific target,        has satellite facilities at Memorial Hermann Northwest, Memorial
destroying the tumor or malformation without affecting normal tis-         City and Southwest hospitals.
sue nearby. The procedure is relatively safe, painless, accurate and
incision-free.                                                             MEMORIAL HERMANN BREAST SERVICES
                                                                           Memorial Hermann Breast Services provides a complete range of
LYMPHEDEMA CLINIC                                                          services, from education on self-examination techniques to the latest
The lymphedema management program offers noninvasive thera-                in diagnostic and treatment procedures. By utilizing needle biopsy
pies to help patients gain control of chronic swelling, or edema, of       diagnostic equipment, the center’s health-care professionals are able
the extremities, attain optimal functioning and maintain limb              to yield more accurate results with the removal of less tissue.
health while reducing or preventing scarring and inflammation of               Understanding the physical and emotional issues associated with
the skin. Complete decongestive therapy consists of manual lym-            breast cancer screening and treatment, the staff at the center provide
phatic drainage (a gentle massage technique), skin care, specialized       patients support and educational materials. Nutritional counseling,
compression bandaging, measurements to track progress in reducing          physical therapy and physical fitness programs have all proven bene-
swelling, patient-specific exercises and education in diet and self-care   ficial, as has the introduction of stress management techniques. ❏
                                                                                                                                                    13
     Cancer Treatment Options

     The physicians associated with Memorial Hermann Cancer Services           laborate with surgeons, pathologists, radiation oncologists and other
     evaluate and design individual patient treatment plans based on the       medical specialists to plan the optimal course of treatment.
     type, stage and aggressiveness of the patient’s disease. Our oncology     Treatment plans may include surgery, chemotherapy, radiotherapy,
     teams of physicians, nurses, therapists and social workers focus on       biological therapy, stem cell therapy, hormonal therapy, antibody
     meeting the emotional and physical needs of patients and families,        therapy or other investigational therapies, such as whole-body
     striving always to convey hopefulness throughout all stages of            hyperthermia. The medical oncologist makes important medical
     patients’ diseases as well as providing comfort to the terminally ill.    judgments throughout the cancer patient’s course dealing with ane-
                                                                               mia, infection, pain control and other complications which may
     SURGICAL ONCOLOGY                                                         impact overall survival.
     Surgery is the first line of attack in the battle against some cancers,
     particularly tumors of the skin, breast and digestive system. The sur-    RADIATION ONCOLOGY
     geons associated with the cancer programs at Memorial Hermann             Radiation therapy employs ionizing radiation therapy to treat cancer
     hospitals represent the following specialties:                            as well as some benign diseases. Ionizing radiation therapy injures or
                                                                               destroys cells in the areas being treated by damaging the cells’ genet-
     •   Breast                  •   Neurosurgery
                                                                               ic material, thus making it impossible for the cells to continue to
     •   Colon and rectal        •   Ophthalmology
                                                                               divide and spread. Although radiation damages both normal cells as
     •   Dermatology             •   Plastic and reconstructive
                                                                               well as cancer cells, we rely on the normal cells to repair themselves
     •   General                 •   Thoracic
                                                                               sufficiently for the tissues to recover.
     •   Ear, nose and throat    •   Urology
                                                                                  The two common modalities of radiation therapy used in the
     •   Gynecology
                                                                               treatment of cancer are external beam radiation therapy and
        Sentinel lymphadenectomy is being performed throughout                 brachytherapy. External beam radiation therapy is generally deliv-
     Memorial Hermann hospitals as an alternative to elective lymph            ered by a high-energy linear accelerator in the form of either X-rays
     node dissection. Using this new technique, intraoperative lymphatic       (photons) or electrons. Depending on the energy of the X-ray beam
     mapping and sentinel node biopsy, surgeons can determine the dis-         or electron beam that is used, radiation therapy can be used to treat
     ease status of an entire lymph node basin by identifying, removing        cancer that lies deep within the body or close to the skin surface.
     and examining a single special lymph node called the sentinel node.       The higher the energy of the X-ray or electron beam, the deeper will
     Studies have shown that the pathologic status of the sentinel node        be the deposition of a high dose. Sometimes a combination of X-
     accurately predicts the status of all the lymph nodes along that          rays and electrons is used to deliver a close-to-ideal distribution
     tumor’s drainage pathway. This procedure offers a number of               within the tumor. State-of-the-art radiation therapy is given to
     important advantages over traditional treatment, primarily the abili-     patients at Memorial Hermann Southwest Hospital, Memorial
     ty to avoid formal lymph node dissection and its associated risks,        Hermann Northwest Hospital and Memorial Hermann Memorial
     including scarring, nerve damage and lymphedema.                          City Hospital using sophisticated treatment planning techniques
                                                                               that utilize CT scanning and three-dimensional computerized plan-
     MEDICAL ONCOLOGY                                                          ning. This allows the accurate delivery of radiation therapy to the
     A subspecialty of internal medicine, medical oncology focuses on          tumor with protection of normal tissues. At Memorial Hermann
     the diagnosis and medical treatment of solid malignant tumors and         Hospital, certain types of brain tumors as well as some types of
     malignant hematologic disorders. Medical oncologists establish and        benign lesions can be treated with the Gamma Knife, a highly spe-
     evaluate the cancer diagnosis, determine the cancer’s stage and col-      cialized type of external beam radiation therapy.
14
    Another modality of radiation therapy that is available to patients   treatment sometimes requires that the patients remain in the hospi-
treated at hospitals in the Memorial Hermann Healthcare System is         tal for up to a few days. Intracavitary irradiation is often used in the
brachytherapy. This treatment involves the placement of radioactive       treatment of patients with cancer of the cervix and uterus.
sources into either a natural body cavity or directly into the tissues    Interstitial irradiation is used in the treatment of certain head and
involved by the tumor or surrounding the tumor. A high dose of            neck cancers and is increasingly being used in the treatment of some
radiation therapy is concentrated in the area of the tumor, and the       prostate cancers. ❏
tissue surrounding the tumor receives a much larger dose. This



Research/Institutional Review

The Memorial Hermann Healthcare System offers its network of              (FDA) regulations and Office for Protection from Research Risk
physicians and health-care professionals opportunities to participate     (OPRR) regulations, with a strict focus on patient rights and patient
in research at all the Memorial Hermann facilities. Investigators         safety. A variety of research studies are monitored, including clinical,
interested in participating in research submit a research proposal        survey and quality-of-life studies.
(protocol) to the Memorial Hermann Hospital System Institutional             Oncology protocols provide cancer patients with alternatives to
Review Board (IRB) or The University of Texas-Houston Health              standard treatments. These studies allow investigators to test new
Science Center Committee for Protection of Human Subjects.                methods of preventing, screening, diagnosing and/or treating a dis-
   These multidisciplinary bodies include physician specialists, cler-    ease. Breast, lung, leukemia/lymphoma, prostate and pancreatic
gy members, pharmacists, registered nurses, legal members,                protocols are just a few of the latest clinical research options avail-
administrative representatives and community representatives. Each        able to patients at our facilities. For more information regarding
IRB monitors clinical investigations to ensure that research is con-      submitting a research proposal to the IRB or to participate in an
ducted according to the United States Federal Drug Administration         ongoing research trial, please call 713-500-5829. ❏



Ancillary Services

PHARMACY                                                                  SOCIAL SERVICES
The Memorial Hermann pharmacies serving our programs partici-             Memorial Hermann Cancer Services oncology social workers help
pate in the development of policies regarding compliance with laws        patients handle the incidental challenges associated with a cancer
and accreditation standards. They also monitor adverse drug reac-         diagnosis, including governmental benefits, financial concerns,
tions and help ensure the safe and effective use of medications by        lifestyle changes, discharge planning and information or referral to
our cancer patients.                                                      support groups and community agencies.

                                                                                                                                                     15
     CHAPLAINS AND VOLUNTEERS                                                  PALLIATIVE CARE
     Memorial Hermann chaplains offer spiritual guidance to patients           For cancer patients who cannot be cured, palliative or hospice care
     and their families on request. They provide spiritual and emotional       offers symptomatic relief, nursing care and psychological and spiri-
     support as well as short-term counseling and prayer. In addition,         tual support for patient and family. Inpatient or at-home hospice
     our volunteers share their time and talents.                              care is arranged through Houston-area hospice programs.

     REHABILITATION                                                            SUPPORT GROUPS TO ENHANCE RECOVERY
     Rehabilitation services offered through our programs give cancer          Memorial Hermann Cancer Services offers a variety of free support
     patients the support, treatment, education and professional care to       groups for cancer patients and their families. Breast cancer support
     continue their daily activities. Under the direction of a physiatrist,    groups enable patients to share experiences, problems and solutions.
     our interdisciplinary team assesses each patient’s physical condition     The American Cancer Society Reach to Recovery program offers
     and limitations, then helps patient and family set realistic goals. All   free information and valuable psychological support to breast cancer
     of our rehab programs include education to help patients under-           survivors through one-on-one visits by trained volunteers who have
     standing their illness, adjust to lifestyle changes and return to         had breast cancer surgery. The volunteers visit newly diagnosed
     optimal functioning.                                                      patients and provide information, literature and emotional support
                                                                               as well as demonstrate exercises and discuss post-surgery follow-up
     ENTEROSTOMAL NURSING                                                      programs. The Us Too Prostate Cancer Support Group helps can-
     Our programs include the services of an enterostomal therapist or         cer patients and their families cope with the disease and its
     ostomy nurse. These registered nurses are trained in the care of          symptoms. Look Good . . . Feel Better, a beauty program of the
     ostomies and ostomates, greatly enhancing our ability to support          American Cancer Society, offers advice about hair, nail and skin care
     cancer patients with stomas.                                              and make-up application to enhance the self-image of cancer
                                                                               patients undergoing chemotherapy or radiation treatment.
     DIETARY
     Cancer patients are at increased risk of developing nutritional defi-     THE MIND/BODY MEDICAL INSTITUTE
     ciencies that could adversely affect their quality of life, their         The Mind/Body Medical Institute of the Memorial Hermann
     tolerance of treatment and, in some cases, their survival. Working        Healthcare System, an affiliate of the Mind/Body Medical Institute
     with physicians, oncology nurses, patients and families, our regis-       of Harvard Medical School, treats the whole person: mind, body
     tered dietitians identify those who are at nutritional risk and           and spirit. Its new cancer program complements the patients’ med-
     develop realistic goals for them based on a comprehensive nutrition-      ical treatment by helping them reduce the physical symptoms of
     al assessment. They also provide patient and family education and         cancer and its treatment, regain a sense of control and well-being,
     counseling toward achieving these goals.                                  change lifestyle behaviors, manage stress and better cope with side
                                                                               effects of chemotherapy and radiation treatment. This comprehen-
     HOME HEALTH                                                               sive treatment program helps prepare patients to manage their
     The services of Memorial Hermann Home Health include an onsite            symptoms by reaching a physical state of deep relaxation that
     infusion pharmacy, infusion therapy in homelike suites, respiratory       changes physical and emotional responses to stress. ❏
     therapy, skilled and private-duty nursing, rehab services and home
     medical equipment.

16
Memorial Hermann
Cancer Services
Program Reports




                  17
                                       Memorial Hermann Healthcare System
                                       2002 INCIDENCE OF PRIMARY SITES
                                                                                                                                                                     KIMBLE
                                                              2002                            Memorial Hermann Healthcare System*                  U.S. Figures**
                                         Site                                                   No. of Patients          %                    No. of Patients      %
                                         All sites                                                   3,055              100                    1,284,900          100
                                         Lip & oral cavity                                              42               1.4                       16,900          1.3
                                         Pharynx                                                         7               0.2                        8,600          0.7
                                         Other oral cavity                                               8               0.3                        3,400          0.3
                                                                                                                                                                    UVALDE

                                         Esophagus                                                      25               0.8                       13,100          1.0
                                         Stomach                                                        52               1.7                       21,600          1.7
                                         Small intestine                                                16               0.5                        5,300          0.4
                                         Colon                                                         230               7.5                      107,300          8.3
                                         Rectum & rectosigmoid juncture                                105               3.4                       41,000          3.2
                                         Anus & anal canal                                              12               0.4                        3,900          0.3
                                         Liver & intrahepatic bile ducts                                50               1.6                       16,600          1.3
                                         Pancreas                                                       73               2.4                       30,300          2.3
                                         Other digestive organs                                         22               0.7                        4,400          0.3
                                         Larynx                                                         20               0.6                        8,900          0.7
                                         Lung & bronchus                                               400             13.1                       169,400         13.2
                                         Other respiratory                                               6               0.2                        4,900          0.4
                                         Bones & joints                                                  4               0.1                        2,400          0.2
                                         Soft tissue                                                    21               0.7                        8,300          0.6
                                         Skin/melanoma                                                  40               1.3                       53,600          4.2
                                         Breast                                                        560             18.3                       205,000         16.0
                                         Cervix uteri                                                   36               1.2                       13,000          0.1
                                         Corpus uteri                                                   83               2.7                       39,300          3.0
                                         Ovary                                                          37               1.2                       23,300          1.8
                                         Other female genital                                           12               0.4                        5,800          0.4
                                         Prostate                                                      395             12.8                       189,000         14.8
                                         Testis                                                         16               0.5                        7,500          0.6
                                         Other male genital                                              3               0.1                        1,200          0.1
                                         Bladder                                                       109               3.6                       56,500          4.4
Excludes basal and squamous cell
                                         Kidney & renal pelvis                                         103               3.4                       31,800          2.5
carcinoma of skin and in situ carci-
                                         Ureter & other urinary organs                                   4               0.1                        2,400          0.2
nomas, except bladder cancer. Data
                                         Eye                                                             7               0.2                        2,200          0.2
are based on analytic cases. Due
                                         Brain & central nervous system                                155               5.1                       17,000          1.3
to rounding, percentages may not
                                         Thyroid & other endocrine                                      78               2.5                       22,700          1.8
equal 100.
                                         Hodgkin lymphoma                                               20               0.6                        7,000          0.5
                                         Non-Hodgkin lymphoma                                          114               3.7                       53,900          4.2
                                         Multiple myeloma                                               23               0.7                       14,600          1.1
In 2002, Memorial Hermann The            Acute lymphocytic leukemia                                      5               0.2                        3,800          0.3
Woodlands Hospital reported 574          Chronic lymphocytic leukemia                                   19               0.6                        7,000          0.5
cancer cases. Since it has no formal     Acute myeloid leukemia                                         20               0.6                       10,600          0.8
cancer registry in place, a separate     Chronic myeloid leukemia                                        5               0.2                        4,400          0.3
report for The Woodlands is not          Other leukemia                                                 16               0.7                        5,000          0.4
included.                                Other/unknown primary***                                      105               3.4                       30,200          2.3

                                         * Memorial Hermann Healthcare System Cancer Registries: Hermann, Katy, Memorial City, Northwest and Southwest
                                        ** American Cancer Society, Cancer Facts & Figures 2002
18                                     *** “Other” includes ill-defined sites and hematopoietics
                                         TRINITY


                                                    POLK

                                WALKER
             BRAZOS
                       GRIMES



                                MONTGOMERY
                                                                       ORANGE
                                                                                                                      2002 SKIN CANCER SCREENING
          WASHINGTON
                                                    LIBERTY

                                                                 JEFFERSON                                               MEMORIAL HERMANN                     MC        NW         SW
               AUSTIN WALLER
FAYETTE                            HARRIS                                                                                HOSPITALS
                                                           CHAMBERS                                                      Total screened                       139        39        132
          COLORADO
                           FORT BEND
                                                                                                                         Seborrheic keratosis                  44         6         68
                                               GALVESTON                                                                 Actinic keratosis                     40         6         37
                 WHARTON                                                                                                 Dysplastic nevus                      17         3          6
                                   BRAZORIA
                                                                                                                         Congenital nevus                      11         0          3
                                                                                                                         Basal cell carcinoma                  11         5         20
                       MATAGORDA
                                                   2002 PREVALENT COUNTIES                                               Squamous cell carcinoma               10         2          6
                                                   SERVED BY OUR PROGRAMS                                                Melanoma                               0         0          0
                                                   (Hermann, Katy, Memorial City,                                        Other                                 36        17         37
                                                   Northwest and Southwest)

                                                                         Number of Percent of
                                                     COUNTY
                                                                          Patients Patients
                                                     Harris                3,074      75.3      2002 PROSTATE CANCER SCREENING
                                                     Fort Bend               367       9.0
                                                     Brazoria                 72       1.8                                               KATY         MEMORIAL CITY           NORTHWEST         SOUTHWEST
                                                     Austin                   53       1.3                                           #          %        #    %                #    %            #    %
                                                     Montgomery               52       1.3        TOTAL SCREENED                    45                 208                    56               207
                                                     Galveston                42       1.0        RACE
                                                     Waller                   35       0.9        White                             38     84.0        123      64.7          41    73.2       142      68.6
                                                     Wharton                  24       0.6        Black                              1      2.3         36      19.0           9    16.0        21      10.1
                                                     Liberty                  23       0.6        Hispanic                           4      9.0          8       4.2           6    10.7        20       9.7
                                                     Jefferson                19       0.5        Asian                              1      2.3          7       3.7           0       0        20       9.7
                                                     Matagorda                18       0.4        Other                              1      2.3         16       8.4           0       0         4       1.9
                                                     Colorado                 14       0.3        DIGITAL RECTAL EXAM
                                                     Washington                9       0.2        Normal                            19     42.0        110      57.9          46    82.1        77      37.2
                                                     Polk                      9       0.2        Abnormal-not suspicious            0        0          0         0           0       0         4       1.9
                                                     Walker                    9       0.2        Abnormal-suspicious                4      9.0         13       6.8           0       0        12       5.8
                                                     Chambers                  8       0.2        Benign prostatic hypertrophy      22     49.0         65      34.2          10    17.9       114      55.1
                                                     Brazos                    7       0.2        None performed                     0        0          2       1.1           0       0         0         0
                                                     Orange                    6       0.1        PSA RESULTS
                                                     Fayette                   5       0.1        Normal                            37     82.0        178      93.7          55    98.2       185      89.4
                                                     Trinity                   5       0.1        Abnormal                           8     18.0         12       6.3           1     1.8        22      10.6
                                                     Grimes                    5       0.1        OVERALL RESULTS
                                                     Other in state*         149       3.6        Abnormal DRE                       1      2.2         13       6.8           0       0         12      5.8
                                                     Out of state             69       1.7        Abnormal PSA                       4      8.8         12       6.3           1     1.8         22     10.6
                                                     Out of country            9       0.2        Abnormal PSA and DRE               3      6.6          3       1.6           0       0          2      1.0
                                                     Total (analytic       4,083     100.0      In September, Memorial Hermann Cancer Services offered free prostate cancer screening exams. These exams included
                                                     and non-analytic)
                                                                                                a digital rectal exam (DRE) and a blood test known as PSA (prostate-specific antigen).
                                                   *Counties in which less than five patients
                                                    were served
                                                                                                                                                                                                               19
                       Memorial Hermann Hospital

                        With the vision and support of the Memorial Hermann Hospital           therapy or as an adjunct to neurosurgery. The Memorial Hermann
                       administration and the multidisciplinary leadership of the Cancer       Radiology department has added Ytrium-microspheres for treatment
                       Committee, the Memorial Hermann Hospital Cancer Program con-            of metastases or primary tumors of the liver. It has also established
                       tinues to make strides by increasing the awareness of all aspects of    the percutaneous radiofrequency ablation procedure for tumors of
                       the Cancer Program. The Cancer Committee is committed to con-           the liver and lungs, with future procedures in breast and other
                       tinuous accreditation as a Teaching Hospital Program by the             organs. The Lymphedema Clinic, one of the most comprehensive
                       American College of Surgeons, Commission on Cancer.                     programs in the city, serves patients of the entire Memorial
                           Goals for the Cancer Program this year included promoting an        Hermann system with its satellites in different hospitals within the
                       increased understanding and compliance with the AJCC TNM                city.
                       staging, promoting and overseeing screening programs and support-           The Cancer Committee continues to play an important role by
                       ing and encouraging continued participation in local American           identifying ways in which the quality of care for cancer patients can
                       Cancer Society programs, the Susan G. Komen Foundation and              be improved and facilitated at Memorial Hermann Hospital.
6411 FANNIN            annual community health fairs.                                          Thoughout 2002, the committee maintained its commitment to
                           The Cancer Committee had oversight for several quality manage-      provide high-quality, state-of-the-art technology, personalized cancer
HOUSTON, TEXAS 77030   ment studies: The Cancer Program Task Force, Improvements in            care close to home and health education ranging from prevention,
                       Cancer Conference and Evaluation of Care and Treatment of Brain         screening and early detection of cancer through diagnostic, thera-
713.704.4000           Cancer. As the year progressed, the Cancer Committee focused on         peutic, multidisciplinary follow-up and research.
                       implementing the new data manual for Cancer Registry (FORDS)                Multidisciplinary participation on the committee will be expand-
                       and the new AJCC TNM Sixth Edition of staging. The committee            ed next year with the addition of a pain management physician and
                       also adopted the National Comprehensive Cancer Network guide-           also a clinical research nurse or manager. In the years to come, the
                       lines for patient management and treatment. Continued focus was         provision and expansion of quality cancer services will continue to
                       given to ensuring documentation of the use of CAP protocols rec-        be primary consideration of the Memorial Hermann Cancer
                       ommended as of Jan. 1, 2001, and mandated as of Jan. 1, 2004.           Program.
                           Memorial Hermann Hospital’s Cancer Program holds a weekly
                       cancer conference. The goal is to improve the care of patients
                       through education and consultation of physicians and hospital staff.
                       Attendance at multidisciplinary cancer conferences has increased
                       significantly this year and has provided the opportunity for consul-
                       tative services.
                           Cancer Services at Memorial Hermann Hospital continues to           Luis T. Campos, M.D., and James H. Duke, M.D.
                       serve the community with highly skilled physicians and treatment        Co-chairmen
                       options. Dr Craig Fischer is fully dedicated to surgical oncology and   Cancer Committee
                       is a fellow of the American College of Surgeons. Neurosurgical
                       Services with Dr. William Gormley has continued to lead the city
                       with surgical interventions in tumors of the central nervous system.
                       Dr. Clive Shkedy, radiation oncologist, has expertise in Gamma
                       Knife radiosurgery, offering an alternative to conventional radiation

20
CANCER CONFERENCES                                                                                                                                      CANCER COMMITTEE

The cancer conference is a patient-oriented, multispecialty weekly conference. Several patients are discussed with their radiological studies
and pathology slides presented by a member of that respective department. Faculty, residents, fellows, house staff and medical students in
Oncology Services, Surgery, Pathology, Radiology, Nursing and visiting physicians attend this conference. In 2002, the average number of
physicians attending increased significantly to 24 and included multidisciplinary physicians from Memorial Hermann Hospital, The
University of Texas Medical School and The University of Texas M. D. Anderson Cancer Center. Conferences focus on pretreatment evalu-
ation, consultations, staging, treatment strategy and patient management. Treatment options are discussed in detail utilizing national and              Luis T. Campos, M.D.        James H. Duke, M.D.
                                                                                                                                                        Chairman                    Co-chairman
international studies reported in the medical literature. The clinical trials that are available to conference patients are also reported.              Medical Oncology            (physician liaison)
                                                                                                                                                                                    General Surgery

                                                                                                                                                        PHYSICIAN MEMBERS
  CANCER CONFERENCES – 2002 PRIMARY SITES PRESENTED                                                                                                     Steven J. Allen, M.D., Hospital Medical Director,
                                                                                                                                                             Assistant Vice President
  Lung                         15     Liver                            4   Kidney                         3                                             Bruce J. Barron, M.D., Radiology
  Stomach                       4     Testis                           1   Pancreas                       4                                             Joan M. Bull, M.D., Medical Oncology, Registry
                                                                                                                                                             Advisor
  Prostate                      4     Bladder                          2   Multiple myeloma               1                                             Donna M. Calabrese, M.D., Internal Medicine,
  Thyroid                       1     Gall bladder                     1   Esophagus                      3                                                  Pulmonary
                                                                                                                                                        Anwar I. Farhood, M.D., Pathology
  Breast                       14     Colon/rectum                     8   Tongue                         1                                             Nelson A. Fernandez, M.D., Pulmonary
  Hodgkin lymphoma              4     Skin                             6   Endometrium                    3                                             Craig P. Fischer, M.D., General Surgery
                                                                                                                                                        Arthur Hamberger, M.D., Radiation Oncology
  Lymphoma                      2     Brain                            6   Unknown primary                1                                             William Keith Hoots, M.D., Pediatrics
                                                                                                                                                        Jeffrey Katz, M.D., Anesthesiology
  Total                                                                                                  88
                                                                                                                                                        Alberto A. Maillard, M.D., Otolaryngology
                                                                                                                                                        Akira Nishikawa, M.D., Cardiology
                                                                                                                                                        Harry R. Price, M.D., Medical Oncology
                                                                                                                                                        Latisha A. Smith, M.D., Anesthesiology
CANCER REGISTRY                                                                                                                                         Dani Zander, M.D., Director, Pathology

                                                                                                                                                        OTHER MEMBERS
The Cancer Program at Memorial Hermann Hospital is accredited              collected by the registry was reported to the Texas Department of            Erin Asprec, Director, Business Development
                                                                                                                                                        Kimberly Benn, Business Coordinator, Transplant
through the American College of Surgeons as a teaching hospital            Health State Cancer Registry, National Cancer Data Base and Call                  Services
cancer program. An approved cancer program consists of a multidis-         for Data. Utilization of the data contributes to the effectiveness of        Patty Fagan, RHIA, Director, Health Information
                                                                                                                                                             Management
ciplinary cancer committee; weekly cancer conferences; performance         the overall care being administered to patients and encourages con-          Greg Harb, Vice President, COO, Memorial
improvement studies; a full range of cancer diagnoses and treat-           tinued and frequent use of the database. This is exemplified in the               Hermann Hospital
                                                                                                                                                        Vickie J. Ladner, CTR, Cancer Registrar
ments; board-certified physicians for all major specialties, including     performance improvement studies conducted for 2002.                          Yvonne Li, MPH, CTR, Cancer Registrar
oncology; and related residency programs.                                      The registry strives for accuracy, timeliness and completeness in        Kathy Luther, RN, Director, Performance
                                                                                                                                                             Improvement
   The Memorial Hermann Hospital Cancer Registry dates back to             all of its duties and responsibilities. The registry’s goal is to continue   Benjamin Price, Medical Staff Services
1994, with over 6,950 cases in the database. The data are available        as a functional and effective data resource that will grow with the          Juanita Romans, Vice President, CEO, Memorial
                                                                                                                                                             Hermann Hospital
for statistical uses by physicians, nurses and other health-care profes-   medical communities throughout the Houston area.                             James Salyer, FACHE, Vice President, CEO,
sionals. The Cancer Registry is an integral part of the Cancer                                                                                               Hermann Children’s Hospital
                                                                                                                                                        Patty Silva, RN, Director, Medicine Services
Program, providing the physicians with long-term follow-up data            Vickie J. Ladner, CTR                                                        Elizabeth Staley, MSW, Social Worker, Oncology
                                                                                                                                                        Linda Tittle, RN, Manager, Oncology Clinic
and treatment outcomes. The Cancer Registry accessioned over 807           Interim Cancer Registry Coordinator                                          Gloria Tobin, RN, MA, MBA, CAN, Director,
new cases in 2002 and maintained an average follow-up rate of over                                                                                           Nursing
                                                                                                                                                        Phyllis Tucker, CMSC, CPCS, Director, Medical
90 percent of all analytic patients into the database. The information                                                                                       Staff Services


                                                                                                                                                                                                     21
                                                       Memorial Hermann Hospital

 NATIONAL COMPARISON                                   2002 PRIMARY SITE DISTRIBUTION BY AJCC STAGE
 OF TOP FIVE SITES*
                                                                     2002                 Class of Case      Sex               AJCC Stage of Diagnosis/Analytic Only
                                                                     Site                   A*     NA*    M       F       O       I     II      III   IV    Unkn NA*
      Lung                                              All sites: 807                     486     321    374    433      18      86     46      46   104      14    172
                                                        Lip & oral cavity                     9      6     10       5      0        4      2       2    1       0      0
      Brain
                                                        Esophagus                             4      8      8       4      0        0      0       4    0       0      0
                                                        Stomach                               8      7      9       6      0        0      0       1    6       0      1
    Breast
                                                        Small intestine                       6      1      3       4      0        2      2       0    1       0      1
     Colon                                              Colon                                24     22     23     23       1        8      5       5    4       0      1
                                                        Rectosigmoid juncture & rectum        5      6      7       4      0        1      1       2    1       0      0
      Liver                                             Anus                                  1      0      1       0      0        0      1       0    0       0      0
                                                        Liver                                23      9     26       6      0        1      2       7   12       1      0
Total top 5                                             Gallbladder & other biliary           8      1      8       1      1        1      0       2    2       2      0
                                                        Pancreas                             22     10     16     16       0        3      1       3   12       2      1
     Other
                                                        Larynx                                2      4      1       5      1        0      0       0    1       0      0
                                                        Lung                                 71     43     58     56       0      11       7       8   43       1      1
              0    10   20    30   40   50   60   70
                                                        Other respiratory                     2      1      3       0      1        0      0       0    0       0      1
                              Percent
                                                        Bones & joints                        0      4      2       2      0        0      0       0    0       0      0
                                                        Soft tissue                           0      6      3       3      0        0      0       0    0       0      0
 Memorial Hermann
                                                        Skin                                  7      8      7       8      2        3      0       1    1       0      0
 Cancer Facts & Figures 2002
                                                        Breast                               42     56      3     95       7      23       7       1    1       3      0
* Based on total cases, with                            Cervix uteri                          2      4      0       6      1        0      0       0    1       0      0
  exclusion of situ carcinomas,
  except urinary bladder                                Corpus uteri                          5      5      0     10       0        3      0       1    1       0      0
                                                        Ovary                                 8      4      0     12       0        2      0       1    4       0      1
 Memorial Hermann Hospital has an                       Vagina & other female genital         2      1      0       3      2        0      0       0    0       0      0
                                                        Prostate                             15     16     31       0      0        1   10         1    3       0      0
 unusually high incidence of brain
                                                        Testis                                2      3      5       0      0        1      1       0    0       0      0
 and other nervous system tumors                        Bladder                               8      4      9       3      1        2      1       1    2       1      0
 and also a high incidence of liver                     Kidney & renal pelvis                18     20     20     18       1        5      2       2    3       1      4
 and intrahepatic bile duct cancers                     Ureter & other urinary organs         1      2      1       2      0        1      0       0    0       0      0
 compared to top five cancer sites in                   Eye                                   7      0      4       3      0        1      0       0    0       2      4
                                                        Brain & central nervous system     115      30     61     84       0        0      0       0    0       0    115
 the U.S. This unusually high inci-
                                                        Thyroid & other endocrine            14      0      3     11       0        8      2       1    1       0      2
 dence likely can be explained by
                                                        Hodgkin lymphoma+                     0      5      2       3      0        0      0       0    0       0      0
 the fact that we are both a neuro-                     Non-Hodgkin lymphoma+                17      8     13     12       0        5      2       3    4       0      3
 surgical center and a center for liver                 Multiple myeloma++                    2      2      3       1      0        0      0       0    0       0      2
 disease.                                               Leukemia++                           15      6     11     10       0        0      0       0    0       0     15
                                                        Other hematopoietic++                 0     13      6       7      0        0      0       0    0       0      0
                                                        Other ill-defined sites               3      1      2       0      0        0      0       0    0       1      2
                                                        Unknown                              18      4     13       9      0        0      0       0    0       0     18

                                                       *A=analytic NA=non-analytic
                                                       +Lymphatic system, including extralymphatic sites ++Hematopoietic system


 22
Memorial Hermann Katy Hospital

The Cancer Committee at Memorial Hermann Katy Hospital and                   In April, we enhanced our community outreach program by
its associated Cancer Registry serve as focal points for educational      expanding our involvement with the Relay for Life, which supports
growth and community awareness. The committee has seen tremen-            the American Cancer Society. Over 100 walkers/runners in the Katy
dous growth over the past year with expansion of its education            area participated in this event, which raised over $130,000.
activities, hospital-based initiatives and community outreach pro-           Forty-five people were screened during our prostate cancer
grams.                                                                    screening program in September. Four abnormal/suspicious cases
    Our educational initiative has seen increased participation from      were referred for follow-up with a staff urologist.
medical staff, with more cases reported and a variety of guest speak-        The Cancer Committee intends to continue expanding current
ers participating in case presentations and related education. This       programs and seeking new and innovative opportunities to raise
growth in staff involvement reflects the quality of the presentations     community awareness of screening techniques for the early detec-
made, the opportunities for education and the CMEs that are               tion of cancer. It also will continue working to improve care for
offered.                                                                  diagnosed cancer patients in partnership with other hospitals in our
    The importance of mammography as a tool for identifying can-          system while striving to maintain state-of-the-art cancer care in the   5602 MEDICAL CENTER DR.
cer at an early, more treatable stage cannot be overemphasized, yet       community setting.
the mammography screening rate statewide is abysmal. Texas ranks                                                                                  KATY, TEXAS 77494
48th among U.S. states and territories in proficiency of mammogra-
phy screening for the Medicare population. To improve these                                                                                       281.392.1111
statistics, we’ve taken steps to increase the number of mammograms
conducted in our community. We offer mammograms at our
Kingsland Clinic and hospital Outpatient Imaging department.              Mark Bing, M.D.
We’re also partnering with the Black-Eyed Pea restaurant on its           Chairman, Cancer Committee
“Easy as a Piece of Cake” program, in which patients who have a
mammogram receive a free desert from the restaurant.
    In 2002, we expanded our CanCare volunteer initiative, which is
designed to improve the quality of life for cancer survivors and their
families. This initiative is led by lab technologist Marianne Stratton,
who is a cancer survivor.




                                                                                                                                                                      23
 CANCER COMMITTEE                                      CANCER CONFERENCES

                                                       Memorial Hermann Cancer Services at Memorial Hermann Katy Hospital hosts monthly cancer confer-
                                                       ences. The multidisciplinary cancer conferences provide consultation services, pretreatment evaluation,
                                                       staging and treatment management discussion. During the past year, there has been increased attendance
                                                       at the conferences, with an average of 10 physicians and five other health-care professionals. There has
                                                       also been added participation by Radiation Oncology and other subspecialties. Physicians are awarded
Mark Bing, M.D.                                        one CME credit hour.
Chairman
Internal Medicine

PHYSICIAN MEMBERS                                        CANCER CONFERENCES – 2002 PRIMARY SITES PRESENTED
J. Richards Adams, M.D., Internal Medicine               Breast                      1     Bronchus                       2    Cervix uteri                 2
E.F. Bartsch, M.D., Family Medicine
Paul Bing, M.D., Pulmonary Medicine
                                                         Colon                       3     Duodenum                       2    Endometrium                  2
G. Russell Edwards, M.D., Obstetrics/Gynecology          Lung                        4     Lymphoma                       1    Multiple myeloma             1
Douglas K. Fernandez, M.D., Gastroenterology             Ovary                       2     Parotid gland                  1    Stomach                      1
Morris Gonik, M.D., Obstetrics/Gynecology
                                                         Testicular                  1     Tongue                         1
William Klinke, M.D., Otolaryngology
R. Dudley Koy, M.D., Pathology                           Total                                                                                             24
Ramesh Krishnan, M.D., Urology
Selina Lin, M.D., Obstetrics/Gynecology
Janet Macheledt, M.D., Medical Oncology
Stephen McElmurry, M.D., General Surgery
Sandra McNees, M.D., Radiology                         CANCER REGISTRY
Edward Mendelson, M.D., Obstetrics/Gynecology
Wilford Morris, D.O., Family Practice
Terence O’Connor, M.D., Radiology
                                                       During 2002, 98 cancer cases were accessioned at the Memorial Hermann Katy Hospital Cancer
David Reininger, M.D., Internal Medicine               Registry. Cancer data management is a key component of a successful cancer program. These data con-
Clive Shkedy, M.D., Radiation Oncology                 tribute to treatment management, staging and continuity of care for patients. Complete workup, staging
Barry Siller, M.D., Gynecological Oncology
Brenda Wainscott, M.D., Internal Medicine
                                                       and planned treatment has been initiated. Annual follow-up of patients is an important cancer registry
                                                       function. A successful follow-up rate of 90 percent is required for survival outcome analysis. The Katy
OTHER MEMBERS                                          registry reports a 97-percent follow-up rate on its eligible patients to maintain the required follow-up
Scott Barbe, Vice President/CEO
                                                       rate of greater than 90 percent
Marilyn Paine, Assistant Vice President/Patient Care
     Services                                             The Cancer Registry of Memorial Hermann Katy Hospital is guided by a Cancer Committee.
Lisa Kendler, Assistant Vice President/CFO             Monthly cancer conferences are held with enthusiastic administrative and medical staff support.
Judy Todnem, RHIA, Director, HIM                          Desirable patient outcomes result from the coordinated effort of all members of the health-care team
Carol Ahlschlager, CTR, Cancer Registrar
Marsha Bourgeois, Director of Business
                                                       as well as administrative and organizational elements that influence the health-care process.
     Development
Steve Dinwiddie, Director, Imaging Services            Carol Ahlschlager, CTR
Jerry Thomas, Chaplain
Kit Lary, RN, Director, QRM
                                                       Cancer Registrar
Jean Sedita, RN, Clinical Director,
     Medical/Surgical




24
Memorial Hermann Katy Hospital

2002 PRIMARY SITE DISTRIBUTION BY AJCC STAGE                                                                               NATIONAL COMPARISON
                                                                                                                           OF TOP FIVE SITES*
                 2002              Class of Case        Sex               AJCC Stage of Diagnosis/Analytic Only
                 Site                A*     NA*     M         F       O       I       II       III   IV   Unkn    NA*
                                                                                                                               Lung
 All sites: 98                        67     31     54        44      3      22       14         5    8     5      10
 Lip & oral cavity                     2      1      2            1   0           1        0     0    0     1       0        Breast

 Larynx                                1      1      2            0   0           0        0     0    1     0       0
                                                                                                                              Colon
 Esophagus                             1      0      1            0   0           0        0     0    1     0       0
 Stomach                               0      1      0            1   0           0        0     0    0     0       0   Corpus uteri

 Small intestine                       1      0      1            0   0           1        0     0    0     0       0
                                                                                                                          Leukemia
 Colon                                 8      3      8            3   0           0        3     2    2     1       0
 Rectosigmoid & rectum                 4      0      1            3   0           0        3     0    0     0       1    Total top 5
 Liver & biliary tract                 0      1      1            0   0           0        0     0    0     0       0
                                                                                                                              Other
 Lung                                 14      8     16            6   0           4        3     1    3     2       1
 Skin/melanoma                         2      1      2            1   1           1        0     0    0     0       0                  0    10    20    30    40   50   60   70
 Breast                                9      2      0        11      2           5        1     1    0     0       0                                   Percent
 Cervix uteri                          1      0      0            1   0           1        0     0    0     0       0
                                                                                                                           Memorial Hermann Katy
 Corpus uteri                          6      1      0            7   0           5        0     1    0     0       0
 Prostate                              2      1      3            0   0           1        1     0    0     0       0      Cancer Facts & Figures 2002

 Testis                                1      0      1            0   0           1        0     0    0     0       0    * Based on analytical cases only
                                                                                                                           with exclusion of carcinoma in situ,
 Other male genital                    1      0      1            0   0           1        0     0    0     0       0      except bladder

 Bladder                               3      3      6            0   0           1        2     0    0     0       0
                                                                                                                           At Memorial Hermann Katy
 Kidney & renal pelvis                 1      0      1            0   0           0        1     0    0     0       0
                                                                                                                           Hospital, the incidence of newly
 Brain & central nervous system        2      0      1            1   0           0        0     0    0     0       2
                                                                                                                           diagnosed lung cancer is higher
 Thyroid & other endocrine             1      0      0            1   0           0        0     0    1     0       0
                                                                                                                           than national averages. The
 Non-Hodgkin lymphoma+                 1      2      1            2   0           0        0     0    1     0       0
                                                                                                                           frequency of corpus uteri malig-
 Leukemia++                            4      6      6            4   0           0        0     0    0     0       4
                                                                                                                           nancies is one-third of the
 Unknown primary                       2      0      0            2   0           0        0     0    0     0       2
                                                                                                                           national estimated new cases
*A=analytic NA=non-analytic
                                                                                                                           for 2002.
+Lymphatic system, including extralymphatic sites ++Hematopoietic system




                                                                                                                                                                        25
                       Memorial Hermann Memorial City Hospital

                       Memorial Hermann Memorial City Hospital is a recognized                  by a licensed psychologist has been established to encourage individ-
                       Comprehensive Cancer Program and is accredited by the American           uals to both quit smoking and remain smoke-free.
                       College of Surgeons. This program relies both on outpatient and             The cancer program hosts the annual Fleishman Family Festival.
                       inpatient multidisciplinary services and on the expertise of qualified   This event engages the community to enjoy festivities while pro-
                       surgeons, pathologists, diagnostic radiologists and medical and radi-    moting healthy lifestyles. The cancer program also holds interactive
                       ation oncologists for the diagnosis and treatment of patients with       sessions with Memorial Hermann Memorial City Hospital physi-
                       cancer. The Tumor Board is an example of this multidisciplinary          cians on cancer-related topics of concern. Our urologists and Lab
                       approach to the treatment of the oncology patient; our physicians        Services staff have joined forces to provide prostate screening to the
                       present two to four oncology cases prospectively each week.              men in our area for early detection of prostate cancer.
                           The Cancer Registry has continued to perform quite well,                One of the most important issues in caring for patients with
                       abstracting more than 1,000 cases a year with a follow-up rate of        cancer is the development of projects and programs that reflect
                       95 percent.                                                              quality assurance and improvement of patient care. Some of these
921 GESSNER                The Oncology unit has been fully staffed, giving our patients        programs include the delineation of the cord compression protocol
HOUSTON, TEXAS 77024   maximum care in a compassionate manner. The use of positive pres-        and a breast biopsy orientation study for tumor and margin designa-
                       sure and HEPA filter rooms has contributed to reducing                   tion. The Cancer Committee has also engaged in a cooperative
713.932.3000           hospital-acquired infections in myelosuppressed patients. Social         program with Baylor College of Medicine for research, adopting
                       Services continues its presence, coordinating discharge planning and     some of the protocols of the National Surgical Adjuvant Breast and
                       terminal care when the intervention of hospice is needed.                Bowel Project (NSABP), which will enhance our institutional
                           The Radiation Oncology department has continued to refine            research. For 2003, the studies will be on esophagitis in patients
                       its equipment with the acquisition of the state-of the-art multi-leaf    receiving chemo-radiation in cancer of the lung and pain control in
                       collimator linear accelerator with record and verify capabilities, an    the Oncology unit.
                       important tool for quality control. A new modality of treatment             Memorial Hermann Memorial City Hospital just opened a nine-
                       with a more precise and intense fractionation delivery of treatment      story medical tower that offers expanded services in emergency
                       will be implemented with Intensity Modulated Radiation Therapy           medicine, surgery, intensive care, neurosciences, orthopedics and
                       (IMRT) and a new program that will deliver high-dose brachy-             general surgery. In addition, the hospital is renovating its existing
                       therapy twice a day in only one week, as opposed to four to six          facility and plans to renovate the Medical Oncology unit with pri-
                       weeks in the conventional manner, for breast, esophagus and              vate rooms. We look forward to the continued opportunity to serve
                       branchogenic tumors, among others.                                       the community with its cancer care needs and hopefully contribute
                           Memorial Hermann Memorial City Hospital remains active               to the early detection and prevention of this dreadful disease.
                       within the community through the facilitation of screening and
                       support groups to encourage both the awareness of cancer and
                       healthy lifestyles. Each quarter, women are able to attend the
                       American Cancer Society-sponsored Look Good… Feel Better on
                       campus. This event promotes body, skin and hair enhancements to
                       enable women to get back into daily routines while undergoing can-       L.T. Campos, M.D.
                       cer treatments. Also, a Smoking Cessation support group overseen         Chairman, Cancer Committee


26
CANCER CONFERENCES                                                                                                                                 CANCER COMMITTEE

Memorial Hermann Cancer Services at Memorial Hermann Memorial City Hospital hosts weekly can-
cer conferences or case presentations designed to offer in-depth discussion of diagnostics and treatment
plans as well as overviews of frequently diagnosed cancers. Presenters cover concurrent, prospective and
retrospective cases in this multidisciplinary forum. An average of 25 physicians attend our weekly cancer
conferences. Physicians are awarded one credit hour in Category 1 from the American Academy of
Family Physicians.                                                                                                                                 Luis T. Campos, M.D.
                                                                                                                                                   Chairman
                                                                                                                                                   Medical Oncology

  CANCER CONFERENCES – 2002 PRIMARY SITES PRESENTED                                                                                                PHYSICIAN MEMBERS
                                                                                                                                                   Joel Abramowitz, M.D., Ph.D., Medical
  Head and neck                 3     Retroperitoneum                 1   Brain & central nervous system 2
                                                                                                                                                        Oncology/Hematology
  Digestive tract              31     Connective tissue               2   Endocrine                       2                                        Joseph Cali, M.D., Colorectal Surgery
  Respiratory                  17     Breast                         24   Lymphatics                     11                                        Jeffrey Charnov, M.D., Pain Management
                                                                                                                                                   Joe Ed Dossey, M.D., General Surgery
  Bone                          1     Female genital                 11   Unknown primary                 2
                                                                                                                                                   Ira Flax, M.D., Gastroenterology
  Blood                         2     Male genital                   11                                                                            Jon Gogola, M.D., Obstretrics/Gynecology
  Skin                          5     Urinary tract                   6                                                                            Frankie Ann Holmes, M.D., Medical Oncology
                                                                                                                                                   Janet Macheledt, M.D., Medical Oncology/
  Total                                                                                                131
                                                                                                                                                        Hematology
                                                                                                                                                   Miguel Miro-Quesada, M.D., Medical Oncology/
                                                                                                                                                        Hematology
                                                                                                                                                   Mahmood Moradi, M.D., Neurosurgery
CANCER REGISTRY
                                                                                                                                                   Adam Naaman, M.D., General Surgery
                                                                                                                                                   George Peddie, M.D., General Surgery (ACoS
An important component of the Cancer Program at Memorial                     During the year, the registry has participated in studies requested        Liaison)
Hermann Memorial City Hospital, the Cancer Registry is responsi-          by our physicians, patient care evaluation studies and data con-         James Salter, Jr., M.D., Pathology
                                                                                                                                                   David Mobley, M.D., Urology
ble for the collection, assimilation and analysis of the hospital’s       tributed to the National Cancer Data Base (NCDB), Impath                 Neil Sherman, M.D., Radiation Oncology
cancer data. Our registry was established in 1992 and is currently        Information Services Database and the Central Registry of the Texas      Clive Shkedy, M.D., Radiation Oncology
abstracting more than 1,000 cases a year. We have a database of           Department of Health. The goals of the registry are to assist our             (Physician Advisor)
                                                                                                                                                   Barry Siller, M.D., Gynecological Oncology
10,384 cases, of which 8,815 are analytical cases. The database pro-      cancer program with planning cancer-related activities and to            James Murphy, M.D., Radiology
vides information about a patient’s type of cancer, its location, stage   increase the use of the registry by our medical staff through timely     Robert Van Zant, M.D., Family Practice
at diagnosis and methods used to treat it. Registry data are moni-        and accurate reporting.
                                                                                                                                                   OTHER MEMBERS
tored for quality through qualitative review of completed abstracts                                                                                Leslie Gertson, LMSW, Social Services
to verify the integrity of the database. Each patient is followed         Ella Vernon, CTR                                                         Patty Harrison, RN, Cancer Registry
annually throughout his or her lifetime, either through the primary       Cancer Registry Coordinator                                              Naureen Ismail, RN, IRB Coordinator
                                                                                                                                                   Agnes Mautner, RN, OCN, Nurse Educator
care physician or through direct contact with the patient or next of                                                                               Jeff Nowlin, Administration
kin, when appropriate. Through this effort, survival data are avail-                                                                               Karen Pace, RN, Manager, 2 South
able to the medical staff. The registry is currently following 5,250                                                                               Jennifer Roberts, Director, Ambulatory Services
                                                                                                                                                   Ruth Sherman, Ph.D., LMPT
patients with a follow-up rate of 95 percent.                                                                                                      Nancy Smith, Chaplaincy
                                                                                                                                                   David Stower, RN, Quality Resource Management
                                                                                                                                                   Angie Tippit, Manager, Radiation Oncology
                                                                                                                                                   Ella Vernon, CTR, Cancer Registry Coordinator

                                                                                                                                                                                         27
                                                         Memorial Hermann Memorial City Hospital

 NATIONAL COMPARISON                                     2002 PRIMARY SITE DISTRIBUTION BY AJCC STAGE
 OF TOP FIVE SITES*
                                                                         2002               Class of Case      Sex               AJCC Stage of Diagnosis/Analytic Only
                                                                         Site                 A*     NA*    M       F       O       I      II     III   IV    Unkn NA*
    Breast                                                All sites: 1,285                  1,048    237    577    708     110     234    271    129    141      70    93
                                                          Lip & oral cavity                    18      2     11       9      0        6       3      1    7       1     0
     Colon
                                                          Esophagus                             4      4      7       1      0        0       1      1    1       1     0
                                                          Stomach                              12      2      8       6      1        0       0      3    6       2     0
  Prostate
                                                          Small intestine                       3      0      2       1      0        0       0      1    0       0     2
      Lung                                                Colon                                83      9     41     51      10      18     15      16    17       6     1
                                                          Rectosigmoid & rectum                35      9     23     21       1        4     10     10     2       4     4
   Bladder                                                Anus                                  3      1      2       2      0        0       2      1    0       0     0
                                                          Liver                                 5      3      4       4      0        0       0      2    2       1     0
Total top 5                                               Gallbladder & other biliary           4      1      2       3      1        0       1      1    1       0     0
                                                          Pancreas                             16      5     10     11       0        1       2      3    5       5     0
     Other
                                                          Larynx                                3      2      4       1      0        3       0      0    0       0     0
                                                          Lung                                125     23     71     77       0      20        9    26    54      16     0
              0    10    20    30    40   50   60   70
                                                          Other respiratory                     2      2      2       2      0        0       0      0    0       0     2
                               Percent
                                                          Bones & joints                        2      0      1       1      0        0       0      0    1       0     1
                                                          Retroperitoneum                       1      1      0       2      0        0       0      0    0       0     1
 Memorial Hermann
 Memorial City                                            Soft tissues                          5      0      4       1      0        0       0      2    0       0     3
                                                          Skin/melanoma                        26      3     18     11      11        6       1      1    4       2     1
 Cancer Facts & Figures 2002
                                                          Breast                              257     34      1    290      54     100     65      22     9       7     0
* Based on analytical cases only
  with exclusion of carcinoma in situ,
                                                          Cervix uteri                          8      1      0       9      0        4       2      0    1       1     0
  except bladder                                          Corpus uteri                         33      7      0     40       2      22        2      3    0       4     0
                                                          Ovary                                11      5      0     16       0        4       0      6    1       0     0
                                                          Vagina & other female genital        12      3      0     15       8        0       2      0    1       0     1
 The top five sites reveal that the
                                                          Prostate                            171     32    203       0      0        3   136      18     6       8     0
 incidence of new cases at Memorial                       Testis                                3      0      3       0      0        1       2      0    0       0     0
 Hermann Memorial City Hospital is                        Penis & other male genital            2      0      2       0      0        0       1      0    0       0     1
 comparable to accumulated nation-                        Bladder                              39      5     33     11      22      10        3      2    1       1     0
 al data. The incidence of breast and                     Kidney & renal pelvis                22      9     19     12       0        9       3      4    6       0     0
                                                          Ureter & other urinary organs         1      1      2       0      0        0       1      0    0       0     0
 lung cancer is higher than the
                                                          Eye                                   0      1      0       1      0        0       0      0    0       0     0
 national average. Our top five sites
                                                          Meninges                             10     12      6     16       0        0       0      0    0       0    10
 represent 58 percent of our 2002                         Brain & central nervous system        7      5      8       4      0        0       0      0    0       0     7
 caseload.                                                Thyroid & other endocrine            27      1      6     22       0      16        4      4    0       3     0
                                                          Hodgkin lymphoma+                     6      0      4       2      0        1       1      1    1       2     0
                                                          Non-Hodgkin lymphoma+                33     17     26     24       0        6       5      1   15       6     0
                                                          Multiple myeloma++                   12      2      8       6      0        0       0      0    0       0    12
                                                          Leukemia++                           13      9     11     11       0        0       0      0    0       0    13
                                                          Other hematopoietic ++               14     18     22     10       0        0       0      0    0       0    14
                                                          Other/unknown                        20      8     13     15       0        0       0      0    0       0    20

                                                         *A=analytic NA=non-analytic
                                                         +Lymphatic system, including extralymphatic sites ++Hematopoietic system
 28
Memorial Hermann Northwest Hospital

In 2002, the accredited Community Comprehensive Cancer                    mentation of a new clinical information and patient management
Program at Memorial Hermann Northwest Hospital continued its              tool. This system-wide operating platform allows physicians to
goal to provide our patients with a full-service cancer center offering   review results, sign documents and, if needed, forward or refuse
quality care close to home.                                               documents. They can access this system via a computer in the hos-
   Cancer Services. In response to the growth of our community,           pital or any computer with Internet access. The increased availability
construction of the hospital’s 165,000-square-foot South Tower            of patient clinical information online is greatly appreciated by all
began. Among the expanded services ultimately benefiting cancer           members of the cancer care team.
patients will be new rooms for general surgery and orthopedic sur-           In the allocation of system financial resources, the Radiation
gery patients. We will also be adding an education center, complete       Therapy department was designated to receive a Phillips CT simula-
with a medical research library, that is open to the public. Ongoing      tor (AcQSIM) and upgraded software for treatment planning.
renovations of the existing North Tower include an expansion of our       The Cancer Committee unanimously agreed to put into practice
intensive care unit, three new surgery rooms and relocation of the        the use of the American Joint Committee on Cancer (AJCC) stag-
oncology unit, increasing capacity by 19 beds. Work should be             ing forms as part of the patient’s permanent medical record as well       1635 NORTH LOOP WEST
completed by July 2004. The purchase of a mobile PET scanner by           as the use of National Comprehensive Cancer Network (NCCN)
the Memorial Hermann Healthcare System enables us to offer                guidelines to benchmark treatment and follow-up procedures for            HOUSTON, TEXAS 77008
advanced radiological technology to our patients.                         our cancer patient population.
   Education. Ongoing cancer awareness was promoted in the                   The Pain Management Program continued in 2002 to assist in             713.867.2000
community throughout the year with our annual skin cancer screen-         evaluating the accuracy of documentation of pain status and
ing in May and our prostate cancer screening in September. We also        response to pain medications at this institution. Another initiative to
participated in many local health fairs. The cancer program promot-       enhance quality care for our patients was a project developed to
ed efforts to educate the community on site-specific cancers, such as     evaluate the incidence and etiology of falls on our oncology unit.
breast, colorectal and lung, with information on potential lifestyle         The Cancer Registry continued to tabulate new diagnoses of can-
changes, early warning signs and access to risk reduction programs.       cer at our institution under the accomplished leadership of our
   Oncology nursing certification and physician education contin-         registrar, Kathy Stevenson.
ued to be accessible by means of oncology in-services and events             Wrapping up 2002. As in any other year, the cancer care team
offered throughout the year. These educational tools included but         at Memorial Hermann Northwest Hospital remains committed to
were not limited to our ongoing weekly cancer conferences and two         examine our care processes and deliver state-of-the-art cancer treat-
guest speakers; Charles Thomas, M.D., of The University of Texas          ment to our cancer patients.
Health Science Center at San Antonio presented “Combined
Modality Approaches for Locally Advanced Non-Small Cell Lung
Cancer,” and Jean-Marc Nabholtz, M.D., of the University of
California-Los Angeles School of Medicine presented “Integration
of Taxanes in Adjuvant Therapy of Breast Cancer.” A digital micro-
scope and software for enhancing film projection were purchased for       T.F. Tenczynski, M.D.
our well-attended weekly cancer conferences.                              Chairman, Cancer Committee
   Quality Care. Patient care was greatly enhanced with the imple-


                                                                                                                                                                     29
CANCER COMMITTEE                                         CANCER CONFERENCES

                                                         The cancer conference (tumor board) at Memorial Hermann Northwest Hospital is a weekly educational
                                                         meeting composed of physicians from a wide variety of specialties committed to the treatment of the
                                                         cancer patient. Case presentations, enhanced by state-of-the-art audiovisual technology, are discussed and
                                                         treatment plans formalized. The board, via this educational, informative conference, is dedicated to the
                                                         sound premise that treatment of the cancer patient is and must be multidisciplinary in nature. This
T.F. Tenczynski, M.D.                                    CME-accredited roundtable discussion is widely attended by physicians as well as nurses, pharmacists
Chairman
                                                         and other health-care professionals.
Medical Oncology

PHYSICIAN MEMBERS                                        W. Mike Ratliff, M.D.
Vinod Bhuchar, M.D., Medical Oncology                    Cancer Conference Moderator
Luke Burke, M.D., Otorhinolaryngology
Joseph Cali, M.D., Colorectal Surgery
Victor Carandang, M.D., Family Practice
Peter Farha, M.D., Medical Oncology                        CANCER CONFERENCES – 2002 PRIMARY SITES PRESENTED
Arthur Hamberger, M.D., Radiation Oncology
                                                           Head and neck                3     Lymphatic system               13   Male genital                  1
Harmohinder Kochar, M.D., Pulmonary Diseases
Gary Leach, M.D., Radiation Oncology                       Digestive tract             31     Endocrine                       7   Hematopoietic                 4
R. Emmett McDonald, M.D., Urology                          Respiratory                 10     Skin                            2   Brain                         2
Roberto Montoya, M.D., Plastic Surgery
                                                           Breast                      19     Connective tissue               2   Unknown primary               2
Nicola Perone, M.D., Obstetrics/Gynecology
William Pfeiffer, M.D., Radiology                          Urinary tract                2     Female genital                 11
Mike Ratliff, M.D., General Surgery (ACoS liaison)         Total                                                                                             109
Christophe Salcedo, M.D., General Surgery
Martin Scheid, M.D., General Surgery
Sergio Soroka, M.D., Pathology
Jose B. Tang, M.D., General Surgery (registry liaison)   CANCER REGISTRY
Bernard G. Vine, M.D., General Surgery (ex-officio)

OTHER MEMBERS
                                                         The Cancer Registry at Memorial Hermann Northwest Hospital is            the monitoring and improvement of quality patient care at this
Jason Adams, Administration                              an information system that brings a variety of uses to an accredited     institution. The registry reports regularly to the Texas Department
Shelita Anderson, RN, OCN, Oncology Nursing              Community Comprehensive Cancer Program. The registry is                  of Health State Cancer Registry and submits annually to the
Rick Chandler, Pastoral Care
                                                         responsible for the collection, management and analysis of data of       National Cancer Data Base.
Linda Dunn, LMSW, Oncology Social Services.
Barbara Gaines, RN, Patient Care Director,               our cancer patient population, making it a valuable research device         The registrar assists with all community outreach activities relat-
     Oncology/Rehabilitation                             for etiology, diagnosis and treatment of cancer. In 2002, 532 new        ing to cancer awareness, prevention and screenings, supporting a
Karen Haney, RN, Director, Rehabilitation Services       cases were added to the database, bringing it to a total of 6,230        goal to aid the medical community wherever possible in the preven-
Diana Howard, RN, Radiation Oncology Nursing
Kathy Stevenson, CTR, Cancer Registrar
                                                         cases. The registry currently follows 2,425 patients with a successful   tion, early diagnosis and treatment of cancer in our patient
                                                         follow-up rate of 96 percent, meeting the requirement of 90 percent      population.
                                                         or greater of the American College of Surgeons Commission on
                                                         Cancer. Physician review of at least 10 percent of the data is con-      Kathy L. Stevenson, CTR
                                                         ducted for quality management assurance. The registrar assists the       Cancer Registry Coordinator
                                                         medical and administrative staff with data requests, strengthening


30
Memorial Hermann Northwest Hospital

2002 PRIMARY SITE DISTRIBUTION BY AJCC STAGE                                                                        NATIONAL COMPARISON
                                                                                                                    OF TOP FIVE SITES*
              2002                 Class of Case      Sex               AJCC Stage of Diagnosis/Analytic Only
              Site                   A*     NA*    M       F       O       I      II     III   IV    Unkn NA*
                                                                                                                       Breast
 All sites: 532                     454      78    249    283      32      73    108      67    80      48    46
 Lip & oral cavity                     5      0      1       4      0        0       0      1    4       0     0         Lung
 Pharynx                               3      0      2       1      0        0       1      0    2       0     0
 Nasal cavity/paranasal sinuses        2      0      0       2      0        0       0      0    0       0     2     Prostate

 Major salivary glands                 2      0      2       0      0        0       1      0    0       0     1
                                                                                                                        Colon
 Larynx                                9      0      9       0      2        5       1      0    1       0     0
 Esophagus                             8      0      4       4      0        0       1      2    3       2     0
                                                                                                                       Kidney
 Stomach                              11      1      5       7      1        0       1      0    3       4     0
 Colon                                54      4     29     29       7        7    14      11     7       8     0   Total top 5

 Rectum & rectosigmoid juncture       19      1     12       8      1        4       2      4    1       6     1
                                                                                                                        Other
 Anus                                  4      0      1       3      0        0       2      1    0       1     0
 Liver                                 8      0      6       2      0        0       0      1    3       4     0                 0    10    20    30    40   50   60   70
 Gallbladder                           1      0      0       1      0        0       0      1    0       0     0                                  Percent
 Extrahepatic bile ducts               2      0      2       0      0        0       1      1    0       0     0
 Pancreas                             11      4      8       7      0        0       1      1    7       1     1    Memorial Hermann Northwest
 Lung                                 64     12     43     33       0        5       1    17    28      13     0    Cancer Facts & Figures 2002
 Bone                                  0      1      1       0      0        0       0      0    0       0     0
                                                                                                                   * Based on analytic cases only
 Soft tissues                          7      1      4       4      0        1       1      1    1       0     3     with exclusion of carcinoma in situ,
                                                                                                                     except bladder
 Melanoma & other skin                 7      1      6       2      1        1       1      2    0       1     1
 Breast                               72     19      0     91      14      19     27        6    4       2     0
                                                                                                                    The total of the top five sites
 Cervix uteri                          8      2      0     10       0        4       2      2    0       0     0
                                                                                                                    comprises more than half of the
 Corpus uteri                         12      0      0     12       0        2       3      3    2       2     0
                                                                                                                    newly diagnosed cancer cases at
 Ovary                                 7      0      0       7      0        2       0      2    1       1     1
                                                                                                                    our institution, with the incidence
 Vagina & other female genital         4      0      0       4      0        1       1      0    1       1     0
 Prostate                             48     14     62       0      0        4    40        4    0       0     0    of breast, lung, colon and kidney
 Testis                                3      0      3       0      0        3       0      0    0       0     0    cancer being higher than the
 Bladder                              15      3     12       6      6        2       2      2    2       1     0    national averages.
 Kidney                               17      3      8     12       0        8       1      2    5       0     1
 Ureter                                1      0      0       1      0        1       0      0    0       0     0
 Brain & central nervous system        8      0      1       7      0        0       0      0    0       0     8
 Thyroid                               5      2      2       5      0        2       1      1    0       0     1
 Hodgkin lymphoma+                     2      0      1       1      0        0       1      0    1       0     0
 Non-Hodgkin lymphoma+                14      1      9       6      0        2       2      2    3       1     5
 Multiple myeloma++                    1      1      1       1      0        0       0      0    0       0     1
 Leukemia++                            7      2      3       6      0        0       0      0    0       0     7
 Other hematopoetic++                  3      3      3       3      0        0       0      0    0       0     3
 Other/unknown                        10      3      5       8      0        0       0      0    0       0    10

*A=analytic NA=non-analytic
                                                                                                                                                                  31
+Lymphatic system, including extralymphatic sites ++Hematopoietic system
                       Memorial Hermann Southwest Hospital

                       The Memorial Hermann Southwest Hospital 2002 Cancer                          The Breast Care Center had its grand opening in the fall of
                       Committee carried out initiatives to improve on various aspects of       2002. Our new 8,500-square-foot Breast Center, with its peaceful
                       pain management, promote and develop oncology nursing staff,             environment, is conveniently located in our Pavilion. This compre-
                       publish an annual report and complete the Breast Center project.         hensive center provides a full range of the most advanced screening
                          Pain management guidelines were established and finalized by          and diagnostic services available today, staffed with nationally recog-
                       the pain management team and the Cancer Committee. Both                  nized, board-certified dedicated breast radiologists who are
                       medical and nursing staff received extensive education on imple-         supported by highly trained mammography and breast ultrasound
                       mentation of these guidelines. These guidelines are implemented          technologists. Breast cancer patients can attain support through our
                       upon physician discretion. The pain management team went a step          oncology nurse and breast cancer support services and resources.
                       further and proceeded to organize a palliative care team. Our Mind/          Our Cancer Committee is proud to share other accomplishments
                       Body Cancer Program augments our goal to help cancer patients by         for the year. More than 70 physicians attended our educational pres-
                       providing non-pharmacological approaches to managing pain and            entation on “PET Imaging in Oncology and Neurology,” which
7600 BEECHNUT          stress inherent in a cancer diagnosis. This is done through teaching     provided information on the usefulness of our in-house PET scan-
                       patients mind/body medicine techniques that include diaphragmatic        ner. In an effort to ensure that our physicians would be ready for
HOUSTON, TEXAS 77074   breathing, mindfulness, guided imagery and meditation.                   the new sixth edition of the AJCC Cancer Staging Manual, we pro-
                          Our administration made a wise decision by hiring our new             vided a videoconference on the new staging guidelines. In addition,
713.776.5000           oncology nurse specialist, Agnes YuAsensi, to serve as our nurse edu-    all of our physicians received a complimentary 6th-edition cancer
                       cator to promote oncology and chemotherapy certification and             staging pocket guide.
                       focus on specialized oncology care improvement practices for our             It has been an honor to serve as chairman of the Cancer
                       cancer patents. Thirty-eight nurses attended a two-day chemothera-       Committee at Southwest and to work with my colleagues and other
                       py course focusing on chemotherapy administration. Many other            members of our staff to improve cancer care for our patients.
                       educational in-services were conducted throughout the year. In
                       addition, a chemotherapy order sheet was created to reduce the risk
                       of errors in chemotherapy administration. Our new oncology nurse
                       set up the Cancer Help Touch Screen program to provide infor-
                       mation to patients, families and staff. The oncology staff also
                       participated in cancer awareness activities for breast, prostate,        Arthur D. Hamberger, M.D.
                       skin and lung cancer.                                                    Chairman, Cancer Committee
                          The Cancer Committee elected to write the 2001 annual report
                       patient-care study on non-Hodgkin lymphoma. Dr. William
                       Velasquez, medical oncologist, worked with our registrar to compile
                       statistics and write a narrative on this malignant process. Since this
                       disease requires a multidisciplinary approach, physicians from vari-
                       ous specialties made contributions to the article. Overall statistics
                       and five-year survival were comparable with published national data.



32
CANCER CONFERENCES                                                                                                                                  CANCER COMMITTEE

Memorial Hermann Southwest Hospital hosts weekly cancer conferences that are designed to offer in-
depth discussion of cancer cases by a multidisciplinary forum. Case presentations encompass discussions
about diagnoses, treatment, survival and quality of life issues. Cases can be either prospective or retro-
spective. Physicians are awarded one credit hour in Category 1 of the Physician’s Recognition Award of
American Medical Association. An average of 21 participants attended the weekly cancer conferences in
2002. We also have a bimonthly multidisciplinary breast conference; in which 98 breast cancer cases                                                 Arthur D. Hamberger, M.D.
                                                                                                                                                    Chairman
were presented in 2002. These cases are included in the cancer conference table below.                                                              Radiation Oncology

                                                                                                                                                    PHYSICIAN MEMBERS
                                                                                                                                                    Richard M. Alexander, M.D., Cardiovascular
                                                                                                                                                        Surgery
                                                                                                                                                    Samuel D. Axelrad, M.D., Urology
                                                                                                                                                    Richard W. Brown, M.D., Pathology
  CANCER CONFERENCES – 2002 PRIMARY SITES PRESENTED                                                                                                 Charles L. Conlon, M.D., Medical
                                                                                                                                                        Hematology/Oncology
  Head and neck                6     Digestive tract               18     Respiratory                 12                                            David Devorkin, M.D., Otorhinolaryngology
  Breast                     119     Lymphatic                     20     Endocrine                    6                                            Benjamin Edery, M.D., Dermatology
                                                                                                                                                    Robert A. Furse, M.D., Medical Oncology
  Skin                         8     Connective tissue              6     Hematopoietic                4                                            Carlos A. Herrera, M.D., Gynecological
                                                                                                                                                        Oncology
  Female genital              12     Male genital                   9     Urinary tract                2                                            Leonard Hershowitz, M.D., Neurology
                                                                                                                                                    Henry B. Holle, M.D., General Surgery
  Nervous system               5     Unknown primary                3                                                                               Michael H. Kleinman, M.D., General Surgery
  Total                                                                                              230                                            T. J. Lawhon, M.D., General Surgery
                                                                                                                                                    Louis E. Neff, M.D., General Surgery (ACoS
                                                                                                                                                        Liaison)
                                                                                                                                                    Bonnie Olney, M.D., Family Practice
                                                                                                                                                    Arlene E. Ricardo, M.D., General Surgery
                                                                                                                                                    Stephen L. Rose, M.D., Radiologist - Breast
                                                                                                                                                        Services
CANCER REGISTRY                                                                                                                                     Kathleen M. Shadle, M.D., Radiation Oncology
                                                                                                                                                    Jay M. Shenaq, M.D., Plastic Surgery
                                                                                                                                                    Ned B. Stein, M.D., Urology
                                                                                                                                                    William S. Velasquez, M.D., Medical Oncology
The Memorial Hermann Southwest Cancer Registry was established                The Cancer Registry at Memorial Hermann Southwest Hospital            Rodolfo L. Villarreal, M.D., Diagnostic
in 1990. It is a case-specific database of information containing the     is guided by a multidisciplinary cancer committee and coordinated             Radiology
                                                                                                                                                    George E. Whalen, M.D., Gastroenterology
type of cancer, primary site, stage of development at diagnosis and       by a cancer registrar. Registry operations are reported routinely to      Blossom Zanger, M.D., Medical
                                                                                                                                                        Hematology/Oncology
treatment regimens. Our cancer database has over 15,000 cases reg-        the Cancer Committee. The registrar at Southwest is credentialed as
istered since the reference date. In 2002, we enrolled more than          a certified tumor registrar and is specially trained in cancer registry   OTHER MEMBERS
                                                                                                                                                    Ann Asnaashari, RN, CCRN, CPHQ,
1,300 new cancer cases.                                                   operations. The registrar is responsible for gathering registry data,        Performance Improvement
                                                                                                                                                    Danielle Baham, RD, Dietary
    Each patient accessioned into the cancer database will be fol-        ensuring quality control and coordinating a weekly cancer confer-         Susie Barone, RD, LD, Mind/Body Medical
                                                                                                                                                       Institute - Director
lowed annually throughout his or her life to update the patient’s         ence. The registrar also coordinates annual skin and prostate cancer      Kathleen Bryant, RHIT, CTR, Cancer Registry
disease status. The Memorial Hermann Southwest Hospital Cancer            screening and participates in local health fairs and cancer fundrais-     Debra Canales-Burbridge, Community Relations
                                                                                                                                                    Cindy Garza, RN, Pain Management Team
Registry follow-up rate for the year ending 2002 was 94 percent.          ing events.                                                               Michael Groves, RN, Administration
                                                                                                                                                    Robin Hanzelka, RHIA, CTR, Cancer Registry
We provide assistance and case accrual to the Texas Department of                                                                                      Coordinator
                                                                                                                                                    Margaret Hindle, LMSW, Social Work
Health and the National Cancer Database. Our Cancer Committee             Robin Hanzelka, RHIA, CTR                                                 Laurie McInnes, MSN, RN, FNP, Breast
encourages utilization of registry data for patient-care evaluations      Cancer Registry Coordinator                                                  Services Director
                                                                                                                                                    Lisa Miller, RPh, PharmD, Pharmacy
and other special studies.                                                                                                                          Clara Quezada, RN, MSN, FNP, Interim
                                                                                                                                                       Oncology Nursing Director
                                                                                                                                                    Michelle Swisher, Breast Services
                                                                                                                                                    Agnes YuAsensi, RN, MSN, OCN, Oncology
                                                                                                                                                       Nursing
                                                                                                                                                                                            33
                                                           Memorial Hermann Southwest Hospital

   NATIONAL COMPARISON                                     2002 PRIMARY SITE DISTRIBUTION BY AJCC STAGE
   OF TOP FIVE SITES*
                                                                           2002               Class of Case      Sex               AJCC Stage of Diagnosis/Analytic Only
                                                                           Site                 A*     NA*    M       F       O       I      II     III   IV    Unkn NA*
      Breast                                                All sites: 1,385                  1,286     99    606    779     182     280    336    131    140      16    201
                                                            Tongue                                5      0      5       0      0        2       1      0    1       0      1
    Prostate
                                                            Mouth                                 3      0      3       0      0        0       1      2    0       0      0
                                                            Pharynx                               4      0      3       1      0        0       1      2    0       1      0
        Lung
                                                            Other oral cavity                     4      1      3       2      0        1       1      0    1       1      0
       Colon                                                Esophagus                             8      0      8       0      0        1       1      1    3       0      2
                                                            Stomach                              23      2     11     14       1        3       5      3    5       0      6
Non-Hodgkin                                                 Small intestine                       6      0      2       4      0        0       1      1    1       0      3
                                                            Colon                                89      9     53     45      10      15     23      22     8       1     10
  Total top 5                                               Rectosigmoid juncture & rectum       48      2     29     21       4        9    16        5    5       1      8
                                                            Anus                                  4      1      1       4      0        2       1      1    0       0      0
       Other
                                                            Liver                                14      1     10       5      0        0       0      3    6       0      5
                                                            Gallbladder & other biliary           9      1      4       6      0        0       3      2    2       1      1
                0    10    20    30    40   50   60   70
                                                            Pancreas                             24      1     16       9      0        1       2      2   12       0      7
                                 Percent
                                                            Larynx                                9      1      9       1      1        3       2      2    1       0      0
                                                            Lung                                126     18     80     64       0      22      11     24    47       0     22
   Memorial Hermann Southwest
                                                            Other respiratory                     3      0      2       1      0        0       0      0    0       0      3
   Cancer Facts & Figures 2002
                                                            Bones & joints                        2      0      2       0      0        0       0      0    0       0      2
  * Based on analytic cases only                            Soft tissue                           9      2      5       6      0        4       1      0    0       0      4
    with exclusion of carcinoma in situ,
    except bladder                                          Skin/melanoma                        23      2     15     10      10        6       0      1    4       0      2
                                                            Breast                              342     19      2    359      85     110     93      15     6       4     29
   A national comparison of our top                         Cervix uteri                         54      3      0     57      36      10        5      3    0       0      0
   primary sites reveals that our                           Corpus uteri                         29      2      0     31       0      15        3      7    2       0      2
   incidence of breast cancer is higher                     Ovary                                11      2      0     13       0        2       2      6    1       0      0
   than the national average. The other                     Vagina & other female genital         5      1      0       6      1        2       1      0    0       0      1
   primary sites are comparable to                          Prostate                            156     10    166       0      0        0   138      13     5       0      0
   national statistics.                                     Testis                                7      0      7       0      0        6       1      0    0       0      0
                                                            Penis & other male genital            2      0      2       0      2        0       0      0    0       0      0
                                                            Bladder                              44      6     38     12      29        7       0      5    1       0      2
                                                            Kidney & renal pelvis                47      1     28     20       1      24        7      4    9       0      2
                                                            Ureter & other urinary organs         3      0      1       2      2        0       0      0    0       0      1
                                                            Eye                                   0      1      1       0      0        0       0      0    0       0      0
                                                            Brain & central nervous system       13      0      7       6      0        0       0      0    0       0     13
                                                            Thyroid & other endocrine            31      2      8     25       0      15        4      3    1       4      4
                                                            Hodgkin lymphoma+                    12      1      8       5      0        0       3      1    3       1      4
                                                            Non-Hodgkin lymphoma+                49      3     31     21       0      17        6      2   16       2      6
                                                            Multiple myeloma++                    8      3      5       6      0        0       0      0    0       0      8
                                                            Leukemia++                           26      2     18     10       0        0       0      0    0       0     26
                                                            Other hematopoietic++                 4      2      5       1      0        0       0      0    0       0      4
                                                            Other/Unknown                        30      0     18     12       0        3       3      1    0       0     23

                                                           *A=analytic NA=non-analytic
   34                                                      +Lymphatic system, including extralymphatic sites ++Hematopoietic system
Glossary of Terms

Adjuvant therapy: Treatment          Hysterectomy: Removal of the        Stage of disease: Extent of dis-     Treatment: Different modali-         Tumor: A new growth of tissue
that follows the primary treat-      uterus by surgery.                  ease as determined at the time       ties (methods) used in the           with continuing, uncontrolled
ment to cure, reduce or control      Invasive cancer: Cancer that        of the first course of therapy.      treatment of cancer.                 spread of cells; also called a
the cancer or relieve symptoms       has spread beyond the area it          In situ: Neoplasm (abnor-             Surgery: Partial or total        neoplasm.
to improve the quality of life.      developed in to involve adja-          mal tissue growth) fulfills all       removal of a tumor (exclud-
AJCC staging classification:         cent tissues.                          microscopic criteria for              ing diagnostic biopsy).
The American Joint                   Non-analytical case: Case              malignancy except invasion.           Radiation: Treatment with a
Committee on Cancer staging          diagnosed and receiving the            Localized: Neoplasm                   radioactive beam or non-
classification.                      first course of therapy elsewhere      appears entirely confined to          beam therapy that includes
Analytical case: Case diag-          prior to the date of referral to       the organ of origin.                  radium implants and
nosed and/or receiving all or        the facility; case diagnosed at        Regional: Neoplasm has                radioactive isotopes.
part of the first course of thera-   autopsy.                               spread to adjacent organs or          Chemotherapy: Treatment
py at a facility.                    PET (positron emission                 tissues and/or has metasta-           of disease by chemical
Angiogenic: Able to grow             tomography) scan: Imaging              sized to regional lymph               agents.
blood vessels, a common fea-         technique that uses radioactive        nodes.                                Radiosurgery: The use of
ture in cancerous tissue.            positrons, or positively charged       Distant: Neoplasm has                 multiple focused radiation
Biopsy: Removal of a small tis-      particles, to detect subtle            spread beyond adjacent                beams to destroy a sharply
sue sample to examine under a        changes in the body’s metabo-          organs or tissues and/or has          defined area without inci-
microscope for cancer cells.         lism and chemical activities that      developed secondary or                sion.
                                     could indicate cancer.                 metastatic tumors, has
Gallium scan: Test, performed                                                                                     Hormone therapy:
by the Nuclear Medicine              Papanicolaou (pap) test: A             metastasized to distant               Administration of hor-
department, to detect inflam-        method of examining tissue             lymph nodes or has been               mones, steroids and
mation, which can be an              cells shed by a body organ, used       determined to be systemic in          endocrine surgery.
indication of tumors or              most often to detect cancer of         origin.
                                                                                                                  Biological response
infections.                          the cervix.                            Unknown: Stage cannot be              modifier (BRM) therapy:
Histology: The science that                                                 determined from the med-              The use of substances that
deals with the microscopic                                                  ical record or by the                 occur naturally in the body
identification of cells and tis-                                            physician.                            to assist in fighting disease;
sues.                                                                                                             also known as immunother-
                                                                                                                  apy.
                                                                                                                  Other combinations: Forms
                                                                                                                  of treatment not appropriate
                                                                                                                  to other categories.
                                                                                                                  No treatment: Includes
                                                                                                                  cases with no report of
                                                                                                                  definitive treatment.
                                                                                                                                                                              35
                                      Information
REFERENCES                            DIRECTORY


American Cancer Society               Memorial Hermann Cancer Services Web Page ..................www.memorialhermann.org/services/cancerservices.html
Cancer, Principles & Practice of      National Cancer Institute...................................................................1-800-4-CANCER; www.nci.nih.gov
Cancer, Sixth Edition, 2001           American Cancer Society ...................................................................Local: 713-266-2877; National: 800-227-2345; www.cancer.org
Commission on Cancer, American        CanCare ..............................................................................................713-461-0028; www.cancare.org
College of Surgeons, National
Cancer Data Base                                                                                      Memorial Hermann Hospital
International Classification of       Administration ........................................................713-704-9077   Pastoral Care (chaplaincy) .......................................713-704-4160
Diseases for Oncology, Third          Cancer Registry.......................................................713-704-5524    Gamma Knife Information .....................................713-704-3365
Edition, 2000                         Nursing Services......................................................713-704-0500                                                               (or 1-800-49-GAMMA
Morrow, C.P., and Curtin, J.P.,       Nutrition Services ...................................................713-704-1112    Social Services .........................................................713-704-4190
Gynecologic Cancer Surgery 1996,                                                                                            Hyperthermia Information......................................713-500-6820
Churchill Livingston, Inc.
National Cancer Data Base,                                                                          Memorial Hermann Katy Hospital
Commission on Cancer Survival
                                      Administration ........................................................281-395-7525   Pastoral Care (chaplaincy) .......................................281-395-7198
Reports 2003, v 1.3
                                      Cancer Registry.......................................................281-395-7595    Nutrition Services ...................................................281-395-7506
National Cancer Institute             Nursing Services......................................................281-395-7525    Social Services .........................................................281-395-7609
National Cancer Institute, Clinical
Announcement, February 1999                                                                  Memorial Hermann Memorial City Hospital
National Institutes of Health         Administration ........................................................713-932-3592   Pastoral Care (chaplaincy) .......................................713-932-3849
National Cancer Institute             Cancer Registry .............................................713-932-3914/3515        Radiation Therapy ..................................................713-932-3500
Surveillance, Epidemiology and
End Results Program (SEER)
                                      Nutrition Services ...................................................713-932-3690    Social Services .........................................................713-932-3477
                                      Oncology Research Nurse .......................................713-932-3564
Neoplasms of the Central Nervous
System, Mosby                                                                                Memorial Hermann Northwest Hospital
Prospective Clinical Trails of
Intracranial Low-Grade Glioma in
                                      Administration ........................................................713-867-3380   Pastoral Care (chaplaincy) .......................................713-867-4463
Adults and Children, American         Cancer Registry.......................................................713-867-2089    Radiation Therapy ..................................................713-867-4668
Society of Clinical Oncology          Nursing Services......................................................713-867-3320    Social Services .........................................................713-867-4657
Recent Developments in the            Nutrition Services ...................................................713-867-3356
Management of Malignant Glioma,
American Society of Clinical                                                                    Memorial Hermann Southwest Hospital
Oncology                              Administration .......................................................713-456-5111    Pastoral Care (chaplaincy) .......................................713-456-5127
SGO Handbook, Second Edition,         Cancer Registry.......................................................713-456-6127    Radiation Therapy ..................................................713-456-5622
January 1997                          Nursing Services......................................................713-456-5116    Social Services .........................................................713-456-8087
World Health Organization             Nutrition Services ...................................................713-456-5437

36
Memorial Hermann Healthcare System

Acute Hospitals                                            Affiliates
Memorial Hermann Children’s Hospital                       Angleton Danbury Medical Center, Angleton
Memorial Hermann Fort Bend Hospital                        Bayside Community Hospital, Anahuac
Memorial Hermann Hospital                                  Columbus Community Hospital, Columbus
Memorial Hermann Memorial City Hospital                    Cuero Community Hospital, Cuero
Memorial Hermann Northwest Hospital                        DePelchin Children’s Center, Houston
Memorial Hermann Katy Hospital                             El Campo Memorial Hospital, El Campo
Memorial Hermann Southeast Hospital                        Fayette Memorial Hospital, La Grange
Memorial Hermann Southwest Hospital                        Frio Regional Hospital, Pearsall
Memorial Hermann The Woodlands Hospital                    Hill Country Memorial Hospital, Fredericksburg
                                                           Hospice at the Texas Medical Center, Houston
Specialty Hospitals                                        Houston Hospice, Houston
                                                           Memorial Medical Center-Port Lavaca, Port Lavaca
Memorial Hermann Continuing Care Hospital
                                                           Northeast Medical Center, Humble
Memorial Hermann Prevention and Recovery Center
                                                           Polly Ryon Memorial Hospital, Richmond
Memorial Hermann Spring Shadows Pines
                                                           Rice Medical Center, Eagle Lake
University Place Retirement Community and Nursing Center
                                                           Sweeny Community Hospital, Sweeny
Memorial Hermann Sugar Land Health Center                                                                           GREATER HOUSTON LOCATIONS
                                                           Tomball Regional Hospital, Tomball
Memorial Hermann Home Health
                                                           Wilson County Memorial Hospital, Floresville
Memorial Hermann-HBU Wellness Center

Managed Hospitals
Memorial Hermann Baptist Beaumont Hospital
Memorial Hermann Baptist Orange Hospital
Yoakum Community Hospital, Yoakum




The 2003 Memorial Hermann Cancer Services                  Cancer Services Editorial Committee:
Annual Report of 2002 Data is published by the             Carol Ahlschlager, CTR; Kathleen Bryant, RHIT, CTR; Robin Hanzelka, RHIA, CTR; Patty Harrison;
Memorial Hermann Healthcare System for physicians,         Vickie J. Ladner, CTR; Kathy Stevenson, CTR; Ella Vernon, CTR; Beth Sartori; and Michaele O’Dwyer
health-care professionals and patients.
                                                           Editor: Anne Feltus
                                                           Design: Peter Layne
                                                           Photography: front cover, inside front cover through page 13, Jim Olive/Photolive, Inc.
Memorial Hermann Healthcare System       Nonprofit
                                       Organization
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