Prostate Cancer Quality Report on Clinical Outcomes by liaoqinmei

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									A Guide for Referring Physicians     2009




                      Prostate Cancer
                      Quality Report on
                      Clinical Outcomes




                                   A MaineHealth Member
                                       Table of Contents




                                  Medical Director’s Message  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 2
                                  Maine Medical Center Cancer Institute (MMCCI) Overview  .  .  .  .  .  .  .  .  .  .  . 3
                                  MMCCI Genitourinary Cancer Program Overview  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 9
                                  A Multidisciplinary Approach to Cancer Care  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 11
                                  MMCCI Genitourinary Cancer Clinical Navigator Program  .  .  .  .  .  .  .  .  .  .  . 13
                                  Patient Screening and Diagnostic Resources  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
                                              Diagnostic technology at MMCCI  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 18
                                  Management Options Available at MMCCI  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 20

A nationally recognized, highly   Quality and Outcomes Report  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 23
coordinated and comprehensive                 The MMC Prostate Cancer Database  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
cancer institute that provides                Patient Demographics  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 24
demonstrated quality care
                                              Radical Prostatectomy  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 26
across the entire continuum.
                                              Cryosurgery of the Prostate  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 30
                                              Radiation Therapy  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 31
                                              Chemotherapy  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 36
                                              Conclusion  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 39
                                              References  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 40
                                  Staff Listing  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 42
                                  Clinical Research  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 46
                                  Other Patient & Family Support & Educational Resources  .  .  .  .  .  .  .  .  .  .  .  . 48
                                  Key Outpatient Locations and Contact Information .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 54
                                  How to Refer a Patient .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 57
Maine Medical Center Cancer Institute: Medical Director’s Message



           Welcome                        to the first edition of our Prostate Cancer
                                          Quality Report on Clinical Outcomes,
           Maine Medical Center Cancer Institute’s publication just for you – our
           valued referring physician. This edition provides a review of our
           current Prostate Cancer Program and related services, and highlights
           clinical outcomes data to serve as a resource for you.

                    When you refer a patient to Maine Medical Center’s Cancer
                     Institute, rest assured that we have thousands of positive
                      treatment outcomes as a result of our constant vigilance
                       to fight cancer. We offer more subspecialty-trained
                       physicians who perform more treatments and
                       procedures in oncology services than any other provider
                       in the state – and better skill sets equal better outcomes.
                       We also offer the most nurses with Oncology Nurse
                       Certification in Maine and northern New England – a
                     higher level of training that is nationally-recognized for
                             improving patient outcomes.

                                   Genitourinary cancer care is an evolving and
                                    complex specialty, and we strive to remain at       Maine Medical Center Cancer Institute Overview
                                     the forefront of this field to provide optimal
                                      care for our patients. We believe that it is
                                      important to share outcomes information
                                       with our referring physicians and others
                                       interested in our Prostate Cancer Program
                                        to help guide treatment choices. We
                                        hope that you find this information
                                        helpful and informative.

                                         Sincerely,




                                         Jacquelyn A. Hedlund, MD
                                         Medical Director
                                         Maine Medical Center Cancer Institute
Maine Medical Center Cancer Institute Overview

                                                 Your partner in exceptional cancer care, close to home
                                                 The Maine Medical Center (MMC) Cancer Institute is Maine’s leading provider
                                                 of oncology services for adults and children, offering a depth and breadth of
                                                 clinical quality and expertise unrivaled in northern New England. From prevention
                                                 and early detection to state-of-the-art treatment and clinical trials, as well as
                                                 educational and emotional support, the MMC Cancer Institute is home
                                                 to the most comprehensive array of award-winning cancer care resources in
                                                 the region.


                                                 Cancer care that is nationally recognized
                                                 In 2007, the Maine Medical Center Cancer Institute
                                                 was granted a three-year teaching hospital
                                                 accreditation from the Commission on Cancer (CoC)
                                                 of the American College of Surgeons. MMC is the
                                                 only hospital in Maine to be awarded this highest level of CoC approval. It means
                                                 that the hospital’s oncology program not only voluntarily meets rigorous national
                                                 standards for cancer care but also has earned several commendations, placing it in
                                                 the top five percent of facilities of its size. Only one in four U.S. hospitals that treat
                                                 cancer will receive this recognition – which MMC has consistently earned since its
                                                 first review in 1978.

                                                 Moreover, MMC was one of only two hospitals in all of New England to be awarded
                                                 the CoC’s Outstanding Achievement Award for exceptional performance in 2007.
                                                 To earn this award, a facility must demonstrate excellence in providing a truly
                                                 comprehensive cancer program that includes cancer committee leadership, cancer
                                                 data management, clinical services, research, community outreach, and quality
                                                 improvement.


                                                 What makes MMC’s Cancer Institute exceptional
                                                 The ultimate measure of a hospital’s cancer care quality is reflected in its patient
                                                 outcomes, and MMC’s are superior when compared with national benchmarks –
                                                 particularly in the areas of lung, prostate and genitourinary, colorectal, and
                                                 breast cancers.

                                                 This outstanding track record is the result of many factors:
                                                      • More expert specialists
                                                       The largest number of board-certified and fellowship-trained medical oncologists,
                                                       radiation oncologists, surgeons and other oncology certified healthcare
                                                       professionals practice at MMC - more than any other hospital in Maine.


                                                                                                                                              5
    Maine Medical Center Cancer Institute Overview

      This means that here you have access to a range of cancer expertise that is         • A leader in cancer research and clinical trials
      unparalleled in this region. Our unique expertise includes:                          We believe that clinical research is the best path toward improving patients’
                                                                                           outcomes. The search for new knowledge and ways to provide care has
      •	 The	only	comprehensive	children’s	cancer	program	in	Maine                         special meaning at the Maine Medical Center Cancer Institute. Our focus is on
      •	 Maine’s	first	Cancer	Risk	and	Prevention	Clinic	that	provides	risk	assessment	    research that has a direct impact on patient care. Our basic research science
         resources, genetic testing, and genetic counseling                                program furthers understanding of cancer biology. Currently, there are more
      •	 The	first	multidisciplinary	thoracic	oncology	clinic                              than 250 clinical trials at Maine Medical Center providing state-of-the-art care
                                                                                           to approximately 3,000 patients. Many of our clinical trials are cancer-related.
      •	 The	first	and	only	genitourinary	cancer	program	with	a	dedicated	Clinical	
                                                                                           In fact, MMC is the state’s leader in patient accruals to cancer clinical trials, with
         Patient Navigator
                                                                                           nearly 400 new patients enrolling in various studies in 2006 and 2007 alone.
      •	 The	state’s	only	neuro-oncology	program                                           This accrual rate is nearly double the national benchmark for hospitals our size -
     • Maine’s most experienced cancer team                                                further evidence of our commitment to advancing the fight against cancer.
      There is a wealth of evidence linking higher volume to better patient
                                                                                          • The only comprehensive children’s cancer program in Maine
      outcomes. MMC cares for more cancer patients, including some of the most
                                                                                           The Maine Children’s Cancer Program
      difficult cases in the state, than any other hospital in Maine. Of the estimated
                                                                                           and the Barbara Bush Children’s Hospital
      8,000 people in this state who are diagnosed with cancer each year, more
                                                                                           at Maine Medical Center provide
      than 2,500 – nearly one-third – will turn to MMCCI for some aspect of their
                                                                                           integrated, comprehensive, and clinical
      diagnosis or treatment.
                                                                                           research-based medical care and
     • A coordinated, multidisciplinary care approach                                      psychosocial support services to infants,
      A team approach to cancer care can reduce mortality and improve patients’            children, and adolescents with cancer and
      quality of life. At our Cancer Institute, multidisciplinary specialists work         blood disorders throughout the state of Maine. The Maine Children’s Cancer
      as an integrated team to ensure continuity of care, coordination, and the            Program strives to cure cancer in as many children as possible and to support
      involvement of the patient and family in the treatment and care-planning             families through their experience of living with childhood cancer.
      process. We work hard to maintain communication among our team
                                                                                          • The most oncology-certified nurses
      members, assuring the highest quality of care.
                                                                                           With more oncology specialty-certified nurses than any
     • Sophisticated diagnostic technology                                                 other hospital in Maine, the MMC Cancer Institute offers the
      The medical center offers the most advanced diagnostic imaging modalities            most knowledgeable and skilled nursing staff for cancer
      available,	including	digital	mammography,	PET/CT,	MR	spectroscopy,	and	              care. Many of our oncology nurses practice outpatient care
      a world-class team of radiologists to read and interpret results. In addition,       at the MMC Cancer Institute in Scarborough, while our inpatient oncology
      MMC provides a full range of specialized anatomic and clinical pathology             nurses practice on our Portland campus at our 44-bed Gibson Pavilion, the
      services, including the largest and most extensive molecular diagnostics lab         only dedicated inpatient oncology unit of its size in Maine. MMC also is the
      in Maine. This capability not only aids in early cancer detection and diagnosis      first hospital in Maine to earn the Magnet designation, the highest honor an
      but also enables more targeted and personalized cancer treatments.                   organization can receive for nursing care.

     • Comprehensive, state-of-the-art cancer treatment resources                         • Compassionate, patient-centered care
      MMC offers the most advanced technology and techniques for the care and              We know that patients treated in a caring and supportive environment
      treatment of cancer patients, encompassing medical oncology, surgery, and            respond more successfully to treatment. That’s why we offer comprehensive
      radiation	oncology.	In	fact,	MMC’s	is	the	only	American	College	of	Radiology	        services to help patients and their families deal with the impact of cancer,
      accredited radiation oncology program in Maine.                                      including nutrition, support groups, home health, and palliative care. And
                                                                                           our specially trained navigators are available to help patients make informed
                                                                                           treatment choices and guide them to existing support resources.
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      Maine Medical Center Cancer Institute Overview




                                                                                              MMCCI Genitourinary Cancer Program Overview
    The advantages of a teaching hospital
    Through our affiliation with the University of Vermont College of Medicine and now
    Tufts University School of Medicine, MMC provides a host of unique advantages
    to patients, including the expertise of an accomplished faculty of physicians and
    surgeons available at all times. This translates to improved quality of care, access to
    new treatments and state-of-the-art technologies, specialized medical procedures,
    and superior outcomes and survival rates.

    The Maine Medical Center Cancer Institute offers the region’s most comprehensive
    array of cancer care resources. Mainers can feel confident knowing they have
    access to world-class cancer care close to home.




8                                                                                                                                           9
       MMCCI Genitourinary Cancer Program Overview

     Prostate cancer is one of the most common cancers diagnosed at the Maine
     Medical Center Cancer Institute. Of the 2,534 new cancer cases seen at MMCCI in
     2007, 308 were prostate cancer and 85 percent of new cases diagnosed at MMCCI
     were treated here.

     MMCCI’s Genitourinary Cancer Program provides multidisciplinary, subspecialty
     care in the diagnosis and treatment of prostate cancer to some of the largest
     patient volumes in all of New England and is one of the most advanced
     and comprehensive programs of its kind in the nation. In 2008, the MMC
     Genitourinary Cancer Program was recognized as one of five model prostate
     cancer programs nationally by the Association of Community Cancer Centers.

     This designation demonstrates the success of the program’s strong commitment
     to developing an individualized care program for each prostate cancer patient,
     coordinating prostate cancer care through Maine’s first and only Genitourinary
     Cancer Clinical Patient Navigator service, and providing the most comprehensive
     and advanced treatment options available.

     In addition, Maine Medical Center’s ongoing commitment to the collection
     and reporting of prostate cancer clinical outcomes data reinforces its unique
                         MMC Prostate Cancer Program Overview
     role as both a community hospital and a regional referral center requiring an     A Multidisciplinary Approach to Cancer Care
     unprecedented depth and breadth of services. The Genitourinary Cancer Program
     at MMC’s Cancer Institute consistently demonstrates clinical outcomes that are
     reliably excellent.




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       A Multidisciplinary Approach to Cancer Care




     The Genitourinary Cancer Program utilizes a multidisciplinary forum to discuss            MMCCI Genitourinary Cancer Clinical Navigator Program
     genitourinary cancer patient cases, as well as to discuss quality improvement
     measures designed to improve future care.

     The Genitourinary Tumor Conference meets on the first and third Thursday of each
     month	in	the	Pathology	Conference	Room	at	MMC’s	Bramhall	Campus	from	7	to	
     8 a.m. Cases are submitted in advance to the Genitourinary Cancer Clinical Patient
     Navigator. All genitourinary cancer cases are welcome and are accepted on a
     first-come, first-served basis. Cases are reviewed within this multidisciplinary forum,
     which	includes	Medical	Oncology,	Pathology,	Radiation	Oncology	and	Urology,	as	
     well as other supportive oncology services.

     In addition to the Genitourinary Tumor Conference, the Prostate Cancer Work
     Group meets quarterly on the second Thursday of each month in March, June,
     September, and December at MMC’s Bramhall Campus Pathology Conference
     Room	from	7	to	8	a.m.	Topics	can	be	submitted	in	advance	and	approved	by	the	
     Medical Director of the Genitourinary Cancer Program, Moritz Hansen, MD.




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       MMCCI Genitourinary Cancer Clinical Navigator Program

     Weighing the risks and benefits of prostate cancer treatment is difficult for both            There is no charge to patients for this service and they may call or visit the Clinical
     patients and physicians. This is especially true at a time when patients are still            Patient Navigator as often as needed in order to feel comfortable and confident
     processing their recent diagnosis. At MMCCI, we believe that a well informed                  about their treatment decision.
     patient is an empowered patient – and one who is better able to cope with the
     demands and potential side effects of any treatment strategy they elect. To help              Patient feedback about the Genitourinary Cancer Clinical Patient Navigator program
     patients make the most informed and timely treatment decisions, MMC’s Cancer                  Surveys were sent to roughly 100 prostate cancer patients who were referred to
     Institute provides a dedicated full-time nurse who serves as a Genitourinary Cancer           the MMCCI Genitourinary Cancer Clinical Patient Navigator between April and
     Clinical Patient Navigator.                                                                   June of 2008.

     Patient navigation is a process by which trained oncology nurses guide patients                 •	 100	percent	of	the	patients	rated	the	clinical	patient	navigator	as	excellent	for	being	
                                                                                                        courteous, friendly, sensitive, respectful, and thorough
     through and around barriers in the complex cancer care system. The nation’s first
     patient navigation program was established by Dr. Harold P. Freeman at Harlem                   •	 93	percent	said	they	would	recommend	this	service	to	others	
     Hospital Center in 1990. The program focused on breast cancer patients to help
     improve access to recommended cancer screening services, follow-up, diagnosis,
                                                                                                   How to make a referral
     and treatment in medically underserved populations. For patients newly diagnosed
                                                                                                   To refer a patient, please contact:
     with prostate or other genitourinary cancers, the Clinical Patient Navigator serves
     as an information resource to help them understand their diagnosis and treatment              Jennifer	Powers,	MS,	BSN,	RN,	CCRC
     options.                                                                                      Maine Medical Center Cancer Institute
                                                                                                   Clinical Patient Navigator for Genitourinary Cancer
     The Maine Medical Center Cancer Institute follows the National Comprehensive
                                                                                                   100 Campus Drive, Unit 102
     Cancer Network Clinical Guidelines in Oncology for prostate and other
                                                                                                   Scarborough, Maine 04074
     genitourinary cancers. Once the patient has a good understanding of their
                                                                                                   Telephone: (207) 885-8439
     diagnosis, stage, and treatment options, the navigator will focus on making sure
                                                                                                   Fax: (207) 885-8595
     the patient is aware of the risks and benefits of each treatment option.
                                                                                                   Genitourinary Cancer Clinical Patient Navigator referrals can include:
     Key elements of the Clinical Patient Navigator’s role include:
                                                                                                     •	 All	patients	with	newly	
       •	 Guiding	patients	through	the	healthcare	system,	establishing	rapport	with	newly	
                                                                                                        diagnosed or recurrent
          diagnosed cancer patients, family members, loved ones, and caregivers
                                                                                                        prostate cancer
       •	 Conducting	meaningful	discussions	with	patients	following	their	initial	consultations	
                                                                                                     •	 All	newly	diagnosed	invasive	
          with	physicians	in	Urology,	Radiation	Oncology,	and	Medical	Oncology
                                                                                                        bladder cancer patients
       •	 Actively	identifying	and	addressing	barriers	to	care	that	might	keep	the	patient	from	        requiring bladder removal
          receiving timely and appropriate treatment for their cancer diagnosis (barriers may
                                                                                                     •	 Newly	diagnosed	or	recurrent	
          include health insurance/financial concerns, transportation to and from treatment,
                                                                                                        renal, bladder, testicular, or
          physical/psychosocial needs, communication/cultural needs, or disease management)
                                                                                                        penile cancer patients requiring
       •	 Connecting	patients	with	resources,	healthcare,	and	support	services	in	                      multidisciplinary management
          their communities
                                                                                                     •	 Patients	being	referred	to	the	
       •	 Assisting	the	patient	in	the	transition	from	active	treatment	to	survivorship                 multidisciplinary Genitourinary
                                                                                                        Tumor Conference




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                                                    Patient Screening and Diagnostic Resources

                                                  Prostate Cancer Screening and Education
                                                  Members of the MMCCI Genitourinary Cancer Program participated in the
                                                  MaineHealth Prostate Cancer Screening Guidelines Work Group, which led to
                                                  the following prostate cancer screening guidelines:

                                                    •	 If	the	patient	is	a	candidate	for	screening	(Prostate-Specific	Antigen	and	Digital	Rectal	
                                                       Exam), discuss the benefits and risks of screening and offer patient decision aids.
                                                    •	 If	the	patient	decides	to	forego	screening,	ask	the	patient	whether	or	not	they	want	
                                                       to be screened at each subsequent health maintenance visit or annually.
                                                    •	 If	Digital	Rectal	Exam	(DRE)	is	abnormal	(for	example,	asymmetrical	texture,	nodule	
                                                       present), perform Prostate-Specific Antigen (PSA) test and refer for consideration of
                                                       transrectal	ultrasound	(TRUS)-guided	biopsy.	
                                                    •	 If	PSA	is	<4	and	DRE	is	normal,	continue	to	offer	screening	at	each	health	
                                                       maintenance visit.
                                                    •	 If	PSA	is	≥4	and	/	or	has	doubled	in	≤3	years,	and	DRE	is	normal,	perform	second	PSA	
                                                       within 3 months and consider referral for transrectal ultrasound guided biopsy. Persistent
                                                       PSA > 4 warrants a referral for consideration of transrectal ultrasound guided biopsy.

     Patient Screening and Diagnostic Resources   These screening guidelines were developed to address prostate cancer screening
                                                  for men aged 50 to 74 with no family or personal history of prostate cancer (average
                                                  risk),	or	for	men	age	40	and	over	if	risk	factors	are	present.	Risk	factors	include:	
                                                  African-American males or any male with one or more first-degree relatives who
                                                  have been diagnosed with prostate cancer, especially if diagnosed at a younger
                                                  age.	Routine	screening	is	not	recommended	for	men	of	average	risk	age	75	and	
                                                  over. Screening decisions for men of any age should be individualized and made in
                                                  concert with an informed patient.

                                                  Providing materials to help patients decide whether to be screened is a very
                                                  important element within these guidelines. Currently, evidence does not support
                                                  widespread screening, nor does it support lack of screening.

                                                  The risks associated with post-screening follow-up can have adverse effects
                                                  that should be understood by the patient when deciding whether to be
                                                  screened.	MaineHealth’s	Learning	Resource	Centers	have	patient	decision	aids	
                                                  and other educational materials available for patients and providers. Some of
                                                  those materials include:

                                                    •	 Health	Dialog	–	Is	a	PSA	test	right	for	you?
                                                    •	 Mayo	Clinic	–	Prostate	cancer	screening:	Should	you	get	a	PSA	test?
                                                    •	 Centers	for	Disease	Control	and	Prevention	–	Prostate	Cancer	Screening:	A	Decision	Guide
                                                    •	 Healthwise	–	Should	I	have	a	PSA	test?
16                                                                                                                                                  17
       Patient Screening and Diagnostic Resources

     The MMC Genitourinary Cancer Program sponsors free screening clinics as well as
     free community educational symposiums.

     For more information regarding educational materials or screenings, please visit
     www.mainehealth.org/LRC	or	call	(207)	885-8570.


     Diagnostic technology at MMCCI
     Maine Medical Center’s Cancer Institute offers a complete range of state-of-the-art
     resources for diagnosing and staging prostate cancer.

     Diagnostic imaging
     MMCCI offers a comprehensive array of leading-edge diagnostic imaging
     modalities, including combined anatomic and metabolic imaging, to aid in the
     detection of prostate and other genitourinary cancers and to monitor treatment
     effectiveness. Our capabilities include:

       •	 Three	magnetic	resonance	imaging	scanners
       •	 Magnetic	resonance	spectroscopy
       •	 Three	64-slice	computed	tomography	scanners
       •	 Positron	emission	tomography
       •	 Nuclear	medicine	(bone	scan)

       •	 Ultrasonography	(including	transrectal	ultrasound)

     In addition, our extensive Picture Archiving and Communications System serves as
     a regional resource that enables rapid image sharing and interpretation, helping to
     speed diagnosis.                                                                      microarrays and mass spectrometry to aid in early cancer diagnosis and to look at
                                                                                           the biology of a tumor. With continued advances, our ability to quantitatively and
     Pathology                                                                             qualitatively measure disease predisposition, predict response to therapy, monitor
     Under the direction of Michael Jones, MD, a specialist in genitourinary pathology,    disease progression, and predict recurrence grows stronger.
     the Maine Medical Center Cancer Institute provides a full range of specialized
     anatomic and clinical pathology services – ensuring timely and accurate diagnosis,    For example, the FISH (Fluorescent In Situ Hybridization) test is an important and
     staging, and monitoring of treatment effectiveness.                                   complex test that detects mutations in chromosomes for a number of different
                                                                                           types of cancer, including bladder cancer. This sensitive diagnostic tool, available at
     Molecular diagnostics                                                                 MMCCI, is used for the detection of alterations in the genome on a cell-by-cell basis.
     Molecular diagnostics play an increasingly important role in cancer disease
     management and Maine Medical Center is home to the largest and most
     extensive molecular diagnostics lab in Maine. Based on cutting-edge research
     in two of the most promising biotechnologies – genomics and proteomics –
     molecular diagnostics utilize sophisticated analytical techniques such as



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                                               Management Options Available at MMCCI

                                             Management Options
                                             Maine Medical Center’s Cancer Institute Prostate Cancer Program offers the region’s
                                             most comprehensive array of treatment options. They include:

                                               •	 An	active	surveillance	protocol                 •	 Prostate	seed	implantation	
                                               •	 Open	radical	prostatectomy	                     •	High	dose	rate	brachytherapy
                                               •	 Laparoscopic-/robotic-assisted	prostatectomy	   •	 Hormonal	therapy
                                                  (da Vinci® surgical robotic system)
                                                                                                  •	 Chemotherapy
                                               •	 Cryosurgery	
                                                                                                  •	 Clinical	trials
                                               •	 External	beam	radiation	therapy	



                                             Active Surveillance
                                             PSA-based prostate cancer screening often results in the diagnosis of prostate
                                             cancer in many men who ultimately will not have disease progression during their
                                             lifetime. Early-stage, low-risk prostate cancer is defined as a Gleason Tumor Grade
                                             Score	≤6,	PSA	<10	and	Tumor	Staging	T1c	to	T2a.	Active	surveillance	may	represent	
                                             an appropriate strategy for some of these men.
     Management Options Available at MMCCI
                                             Active surveillance entails closely monitoring a prostate cancer patient’s condition
                                             and proceeding with active treatment only if cancer progression is demonstrated.
                                             In order for this approach to be successful, the patient needs to understand and
                                             comply with the follow-up schedule. Without this cooperation, active surveillance
                                             will not achieve its intended goals.1

                                             The Maine Medical Center Cancer Institute’s active surveillance protocol was
                                             developed in cooperation with MMCCI’s multidisciplinary Prostate Cancer Work
                                             Group. This team of experts has defined when active surveillance is appropriate,
                                             a recommended follow-up schedule for these patients, and at what point
                                             intervention is indicated. This protocol provides a clear understanding of how each
                                             patient’s prostate cancer will be closely monitored.

                                             What is it?
                                             Active surveillance is closely monitoring a prostate cancer patient’s condition and
                                             treating only when cancer progression is demonstrated. This would include a PSA
                                             doubling	time	that	occurs	in	<3	years	or	a	tumor	grade	progression	to	a	Gleason	
                                             score	≥7.	Active	surveillance	is	generally	only	considered	in	men	with	early-stage,	
                                             low-risk disease.




20                                                                                                                                  21
       Management Options Available at MMCCI

     Who is appropriate for it?
       •	 Prostate-Specific	Antigen	(PSA)	<10
       •	 Gleason	score	≤6	(Tumor	Grade)
       •	 T1c	to	T2a	(Tumor	Stage)
       •	 Prostate	Cancer	on	<3	core	biopsies	and	<50	percent	of	any	core	biopsy	

     Follow-up Schedule
       •	PSA	and	DRE	every	3	months	for	2	years,	then	every	6	months	
       •	10-12	core	repeat	biopsy	at	1	year,	and	then	every	3	years	until	age	80	
       •	Optional	transrectal	ultrasound	on	alternate	visits	

     Intervention
       •	For	PSA	doubling	time	<3	years
       •	For	tumor	grade	progression	to	Gleason	score	≥7	on	repeat	biopsy


     Treatment Options
     Curative options for organ-confined disease can be divided into surgical or radiation
     treatments. Surgical removal of the prostate can be performed via open radical              Quality and Outcomes Report
     prostatectomy	(ORP)	or	laparoscopic	robotic-assisted	prostatectomy	(LRAP).	

     Radiation	therapy	can	be	delivered	from	the	outside	using	external	beam	radiation	
     therapy	(EBRT),	with	3-dimensional	conformal	therapy	or	intensity-modulated	
     radiation	therapy	(IMRT).	Radiation	can	be	delivered	internally	with	low-dose	rate	
     permanent	prostate	seed	implants	(PSI)	or	high-dose	rate	(HDR)	temporary	implants.	

     Cryosurgery involves freezing the prostate gland. Prostate cryotherapy is a minimally
     invasive procedure available to patients with favorable-risk disease or locally recurrent
     disease following radiation therapy.

     Unfortunately, there are few direct
     comparisons between surgery and
     radiation therapy, although they are
     generally considered equally effective.
     Prostate cancer data sets which include
     patients treated with surgery and radiation
     therapy – and which are evaluated
     prospectively by the same criteria – will
     be increasingly useful to patients who are
     trying to determine how and where to
     have their prostate cancer treated.

22
       Quality and Outcomes Report

     The MMCCI Prostate Cancer Database                                                   Table 1:
     The MMCCI prostate cancer database includes demographic, pathologic, quality-        2000-2007 MMC Prostate Cancer Surgery and Radiation Therapy Patients
     of-life outcomes, and cancer-specific outcomes. Prostate seed implant patients
     have been evaluated consecutively and prospectively since the inception of                                    ORP                 LRAP                 EBRT          PSI + EBRT            PSI Alone         HDR + EBRT
     the program in 1998. Beginning in 2000, surgical patients have been evaluated
                                                                                                              n          %         n         %          n        %          n         %          n          %        n         %
     consecutively and prospectively.
                                                                                            # PATIENTS       250                  530                  544                  86                  277                  55
     MMCCI’s prostate cancer database provides information about treatment                  AGE
     outcomes to our physicians providing prostate cancer care as well as to referring
                                                                                            Median           61.0                60.0                 71.0                67.0                  67.0                69.0
     physicians. The database compares local outcomes versus national outcomes, and
     ultimately provides patients with accurate information when they are trying to         Range           40-75                42-75               50-85                50-77                47-81               54-80
     make a well-informed choice as to how to treat their prostate cancer.                  <60 yrs          104        41.6      236        44.5      38        7.0        16        18.6       28        10.1       5        9.1

                                                                                            60-70 yrs        124        49.6      250        47.2      183       33.6       38        44.2      139        50.2      25        45.5
     Patient Demographics                                                                   >70 yrs           22         8.8       44        8.3       323       59.4       32        37.2      110        39.7      25        45.5
     From 2000 to 2007, 780 patients underwent a radical prostatectomy, including 168       PSA (ng/ml)
     open radical prostatectomies performed between 2000 and 2003. In November
                                                                                            Mean             7.13                6.29                 11.96               7.51                 6.18                  9.2
     2003, MMC became the first hospital in the state to acquire the da Vinci® surgical
     robotic system, and 530 patients have undergone laparoscopic robotic-assisted          Range          0.4 - 38.7          0.34 - 41.0          0.11-195.0          2.85 - 36.8          0.01 - 19.0          1.9 -164.9
     prostatectomy between 2003 and 2007. Though the vast majority of surgically            <4                42        16.9       79        15.0      49        9.0        6         7.0       26         9.4        4        7.3
     treated patients undergo this minimally invasive approach, the open surgical
                                                                                            4-10             170        68.5      392        74.4      321       59.2       64        74.4      228        82.3      29        52.7
     technique remains an option for those with extensive prior abdominal surgery.
                                                                                            >10               36        14.5       56        10.6      172       31.7       16        18.6      23         8.3       22        40.0
     From 2000 to 2007, 962 patients underwent radiation therapy. Of these, 277
                                                                                            GLEASON SCORE ON BIOPSy
     patients underwent prostate seed implantation, 544 external beam radiation
     therapy, and 86 combined brachytherapy and external beam radiation therapy.            <7               150        60.2      315        59.8      190       35.8       16        18.6      245        88.4       1        1.8

                                                                                            7                 78        31.3      179        34.0      221       41.7       65        75.6      32         11.6      22        40.0
     As outlined in Table 1, the demographic distribution of these patients is similar.
     The surgical patients were generally younger than those treated with radiation         >7                21         8.4       33        6.3       119       22.5       5         5.8        -                   32        58.2
     therapy (median age 61 years vs. 70 years). The mean presenting PSA                    CLINICAL STAGE
     level for the surgically treated patients was 6.56 ng/ml compared to 10.17 ng/ml
                                                                                            T1               135        56.7      298        58.7      246       46.3       48        55.8      193        69.7      15        27.3
     for the radiation therapy patients (all surgery cases vs. all radiation cases).
                                                                                            T2                97        40.8      207        40.7      230       43.3       38        44.2      84         30.3      31        56.4

                                                                                            T3                 6         2.5       3         0.6       48        9.0        -                    -                    8        14.5

                                                                                            T4                 -                   -                    6        1.1        -                    -                    1        1.8

                                                                                            M1                 -                   -                    1        0.2        -                    -                    -
           Legend             ORP     Open	Radical	Prostatectomies
                              LRAP    Laparoscopic	Robotic-Assisted	Prostatectomies         RISK
                              EBRT    External	Beam	Radiation	Therapy                       Low              110        46.4      248        49.2      132       25.3       7         8.1       218        78.7       -         -
                              PSI     Prostate Seed Implant
                              HDR     High-Dose	Rate	Brachytherapy                          Intermediate      84        35.4      182        36.1      184       35.3       53        61.6      54         19.5      18        32.7

                                                                                            High              43        18.1       74        14.7      205       39.3       26        30.2       5         1.8       37        67.3

24                                                                                                                                                                                                                                    25
       Quality and Outcomes Report

     Patients are stratified by risk factors into low-, intermediate-, and high-risk             Figure 1:                             Stricture may also form at the sutured
     categories.	Risk	factors	include	clinical	stage	≥T2b,	Gleason	score	≥7,	and	PSA	≥10.	       Operative Outcomes                    junction between bladder and urethra.
     Low-risk patients had none of these risk factors, intermediate-risk patients had one        Figure 1 is a comparison of intra-,
                                                                                                                                       Such strictures may require further
     risk factor, and high-risk patients had two or more risk factors.                           peri-, and post-operative outcomes    dilations and treatment after radical
                                                                                                 following open and laparoscopic/      prostatectomy that can impact urinary
     Pre- and post-treatment urinary symptoms and erectile function are assessed.                robotic radical prostatectomy.        control. In our experience, the stricture
     These quality-of-life parameters are measured in a standardized fashion by both                                                   rate	following	ORP	is	more	than	three	
     Urology	and	Radiation	Oncology.	For	instance,	86	percent	of	surgical	patients	                                                    times	greater	than	for	LRAP,	again	
     have erections adequate for intercourse prior to treatment, while 56 percent of                                        LAP/       suggesting a benefit from improved
     brachytherapy patients were potent prior to treatment. The difference may be                              OPEN       ROBOTIC      visualization and precision. This compares
     a function of the somewhat older patient population with a greater number of                                                      to stricture rates in the literature ranging
     comorbidities treated with radiation therapy.                                                                                     from 0.5 percent to 20.5 percent.7

                                                                                                     Blood                             Standardization of pathologic evaluation
     Radical Prostatectomy                                                                            Loss     955ml       215ml       by MMC’s Department of Pathology has
     High-volume surgical centers that critically evaluate their radical prostatectomies                                               greatly facilitated the aggregate analysis
     have been shown to have superior outcomes.2, 3 Of the 780 radical prostatectomies                                                 of radical prostatectomy specimens.
     performed, complete data and follow-up are available on 633 (81 percent). Follow-                                                 When comparing the distribution
     up data collected at 3 months, 6 months, 12 months, and annually thereafter                                                       of clinical stage and grade to final
                                                                                                Transfusion
     include PSA, # pads/day, and erectile function (EF) score. Clinical failure is defined                     32%         <1%        pathological stage and grade, a trend
     by the strict criteria of any measurable PSA other than zero. A distant failure is                                                toward clinically understaging and
     defined as radiologic evidence of soft tissue or bone metastasis.                                                                 undergrading prostate cancer patients
                                                                                                                                       is noted. In fact, 46 percent (208/456)
     Figure 1 is a comparison of intra-, peri-, and post-operative outcomes following              Hospital
                                                                                                      Days
                                                                                                                                       of patients clinically presenting with
     open and laparoscopic/robotic radical prostatectomy.                                                       3.3          1.4
                                                                                                                                       a Gleason score of six are actually
     Of the open radical prostatectomies, 32 percent had blood transfusions during                                                     found to have higher Gleason scores
     their	hospitalization	as	compared	to	<1	percent	of	the	patients	undergoing	a	                                                     on the final pathologic grading. This
     laparoscopic/robotic	radical	prostatectomy.	Following	ORP,	patients	generally	                                                    demonstrates that nearly half of patients
                                                                                                   Positive
     require two to three days in the hospital, compared to discharge on the day after             Margins                             who are clinically believed to have
                                                                                                               24.1%        18.9%
     surgery	for	most	patients	after	LRAP.	                                                                                            low-risk prostate cancer by biopsy
                                                                                                                                       actually have intermediate- to high-risk
     Positive margin rates refer to the percentage of patients in which prostate cancer                                                prostate cancer in the final surgical
     extends to the surgical margin. Factors that can affect this include cancer volume                                                specimen. This clinical undergrading
                                                                                                  Stricture
     as compared to the overall volume of the prostate, as well as the precision of the                Rate     10%          3%        and understaging of prostate cancer is
     surgical technique. To put this in some perspective, positive surgical margins have                                               similar to other reported large national
     been reported in large national series to occur in 11 percent to 46 percent of                                                    series.8 That a significant percentage of
     radical prostatectomy patients.3,4,5,6	In	our	experience,	the	LRAP	positive	margin	rate	                                          patients presenting to MMC are clinically
     is	nearly	25	percent	lower	than	the	ORP	rate,	suggesting	a	benefit	due	to	improved	                                               understaged and undergraded must be
     magnification, visualization, and technical precision.                                                                            kept in mind when counseling patients
                                                                                                                                       prior to treatment.



26                                                                                                                                                                                    27
       Quality and Outcomes Report

     Since the prevalence of serious side effects of any type of definitive prostate          Figure 2:
     cancer therapy remains significant, the measurement of quality of life following         Urinary Continence Rates (LRAP)
     therapy is important. The evaluation of urinary continence and sexual function
                                                                                              100 %
     remains a crucial quality-of-life parameter to be measured following the treatment.
     Standardized quality-of-life instruments are essential to permit accurate cross-
                                                                                               80 %
     treatment comparisons as well as comparisons to national benchmarks. The MMC
     prostate cancer database evaluates urinary continence in terms of the number
                                                                                               60 %                                                                     3 mos
     of pads used per day at 3, 6, 12, and 24 months after surgery. Erectile function is
     evaluated by patient-administered questionnaire and physician interview using a                                                                                    6 mos
                                                                                               40 %
     validated grading system.9,10
                                                                                                                                                                       12 mos
     The largest prospective multi-center study comparing quality of life after radical        20 %
     prostatectomy, brachytherapy, and external beam radiation therapy was published                                                                                    24 mos
     in the New England Journal of Medicine (NEJM) in 2008.11 This landmark study               0%
                                                                                                         <60          60-69        >70          MMC           NEJM
     provides quality-of-life benchmarks for large academic prostate cancer referral                   n = 236       n = 250      n = 44       n = 530       n = 603
     centers (such as MMC).

     Demographically, the MMC and the NEJM series are very similar for all treatment         Figure 3:
     categories. However, it should be noted that in the NEJM study no distinction           Erection Function Rates (LRAP)
     was made between open and laparoscopic/robotic procedures, and all radical
                                                                                             80 %
     prostatectomies were therefore evaluated collectively. Furthermore, unlike the
     MMC database, the NEJM study did not stratify patients by age. We believe that
     age does play a significant factor in eventual urinary continence as well as erectile   60 %
                                                                                                                                                                       3 mos
     function, both in terms of patient expectation as well as actual outcome. We
     therefore report our data in aggregate, as well as in an age-stratified fashion.        40 %
                                                                                                                                                                       6 mos

     Following radical prostatectomy the MMC series defines complete urinary control         20 %                                                                      12 mos
     as using zero pads per day. Figure 2 demonstrates urinary continence rates in
     our	experience	with	LRAP.	Our	aggregate	continence	outcomes	after	surgery	are	           0%                                                                       24 mos
     virtually indistinguishable from the NEJM study.                                                   <60         60-69        >70          MMC           NEJM
                                                                                                      n = 236      n = 250      n = 44       n = 530       n = 603
     Following radical prostatectomy, the MMC prostate cancer database defines
     the preservation of erectile function as those patients able to achieve erections       by the utilization of a different survey technique for the NEJM study). When
     adequate for intercourse with or without the use of oral agents. Figure 3               stratified by age and comorbidities, younger and healthier patients clearly have
     demonstrates erectile function rates in patients who were potent prior to surgery       significantly better urinary continence and erectile function following surgery.
     and who underwent bilateral nerve-sparing procedures. Our aggregate erectile
     function	outcomes	combining	both	ORP	and	LRAP	at	two	years	after	surgery	               For	LRAP	with	a	median	length	of	follow-up	of	17	months	(range	1	to	52	months),	
     appear to be at least as good as those reported in the NEJM study. (Note: The NEJM      PSA was detectable in 4 percent, 5 percent, and 14 percent for low-, intermediate-,
     study reported on the percentage of men with erections not firm enough for              and high-risk groups, respectively (Table 2).	For	ORP	with	a	longer	median	
     intercourse, with the remaining men having erections firm enough for intercourse.       follow-up, PSA was detectable in 3 percent, 6 percent, and 19 percent; and for
     It should also be noted that a direct comparison to the MMC series is complicated       all surgical patients, PSA was detectable in 4 percent, 5 percent, and 16 percent,



28                                                                                                                                                                                 29
       Quality and Outcomes Report

     Table 2:                                                                                              perineal resection for rectal cancer or other major rectal pathology would not be
     PSA Recurrence                                                                                        appropriate for cryotherapy of the prostate.

                                 ORP                 LRAP          EBRT + Brachy      Brachy Alone
                                                                                                           Radiation Therapy
                           n           %        n           %       n           %      n           %
                                                                                                           In radiation therapy, the higher the dose, the greater the likelihood of cure. There
      Low                3/107         2.8    10/240        4.2     1/7        14.3   3/218        1.4     are multiple maneuvers to safely increase dose with prostate cancer. External
      Intermediate        5/79         6.3    8/174         4.6    5/53         9.4   4/54         7.4     beam radiation therapy, delivered via 3-dimensional conformal therapy, and
      High                7/36         19.4   10/73         13.7   4/26        15.4    0/5             0   intensity-modulated radiation therapy allow for dose escalation while respecting
                                                                                                           the tolerance of the surrounding normal tissue. Image-guided radiation therapy,
      Follow-up
                               38 (1-93)            17 (1-52)           37 (1-89)          33 (1-96)       used	in	conjunction	with	IMRT,	allows	improved	targeting.	This	results	in	further	
      (median, range)
                                                                                                           reduction of the amount of normal tissue included in the radiation beam.
                                                                                                           Brachytherapy – with the use of low-dose rate permanent prostate seed implants
     respectively. Notably only 4 percent of these patients received neoadjuvant                           or high-dose rate temporary implants – allows for an even higher radiobiological
     hormonal therapy. This is an important point as hormonal therapy can delay the                        dose to the prostate.
     detection of prostate cancer recurrences by suppressing PSA for months and even
     years after administration. Overall, 6.1 percent developed a PSA recurrence (i.e.,                    Modern prostate brachytherapy began at Memorial Sloan-Kettering Cancer Center
     prostate cancer recurrence), and 0 percent developed distant metastases during                        in the 1970s with the placement of radioactive seeds using an open surgical
     the follow-up period.                                                                                 procedure. However, without the ability to see the seeds inside the prostate, the
                                                                                                           seeds could not be placed in an even fashion. This led to “hot spots” and “cold
                                                                                                           spots” of radiation, resulting in poor outcomes. With advances in ultrasound
     Cryosurgery of the Prostate                                                                           technology and computer imaging software in the 1980s, the modern technique
     Cryosurgery (cryoablation) of the prostate is achieved through freezing. Typically,                   of transperineal ultrasound-guided implants was developed.
     argon gas is circulated through cryoablation needles to create temperatures of
     -40 degrees Celsius or colder. Circulating the cold argon gas through the needles                     This technique allowed the physician to see the seeds within the prostate and
     creates a lethally cold ice ball that freezes the prostate and the cancer cells that are              deposit them evenly. This transformed what had been a major surgery into a
     within it. Once the targeted area is frozen, thawing is employed, during which the                    one-hour procedure. The Seattle Prostate Institute began prostate seed implants
     thawing process ruptures the cells, destroying these cancer cells.                                    in 1985 in the U.S., and they have now treated over 10,000 patients with 15-year
                                                                                                           published results.13 All physicians at MMC performing prostate seed implantation
     This procedure is typically performed in the hospital setting under anesthesia as                     have received training at the Seattle Prostate Institute.
     outpatient surgery. It may be utilized as a secondary treatment in patients with
     persistent cancer after radiation treatment. Other treatments that could be used                      Our prostate seed program began at MMC in April 1998. From 1998 to 2007,
     are hormonal treatment or more radical salvage prostatectomy. Any type of salvage                     we treated 428 patients with PSI alone or in combination with external beam
     treatment is more difficult after radiation therapy.                                                  radiotherapy	(EBRT)	or	hormone	therapy	ablation.	Evaluable	pre-treatment	
                                                                                                           data included age, stage, Gleason score, PSA, subjective American Urological
     There are data to suggest that patients with a small volume of cancer can be                          Association (AUA) urinary symptoms, and erectile function (EF) score. Patients
     selectively treated with very favorable results using primary cryotherapy for                         were treated with iodine pre-loaded needles using Variseed software. All patients
     the prostate, as compared to radical surgery, brachytherapy, or external beam                         underwent a pre-operative prostate volume study, pubic arch study, and repeat
     radiation.12 Contraindications to this would be prior transurethral resection of                      perioperative volume study. Patients completed post-op CT-dosimetry at 1 month.
     the prostate, significant symptoms of urinary obstruction preoperatively, or a                        Follow-up data collected at 1 month, 4 months, 10 months, and yearly thereafter
     markedly enlarged prostate gland. The patient who has had a previous abdominal                        included	PSA,	AUA	score,	EF	score,	and	DRE.	A	clinical	failure	was	defined	as	three	


30                                                                                                                                                                                                31
       Quality and Outcomes Report

     consecutive	rises	in	PSA	by	the	American	Society	for	Therapeutic	Radiology	and	           Figure 4:
     Oncology criteria.14 A distant failure was defined as a positive bone scan.               Patients (%) with AUA Score 0-7
                                                                                               returning to baseline after treatment
     The post-operative dosimetry at one month is a critical part of our quality control
     program to determine if the distribution of the seeds is adequate. Several measures
     of adequacy have been tracked over time. One measure, the D90 (dose to 90                 PSI             100 %

     percent of the prostate), has recently been shown to be predictive of outcome in a                         80 %
     survey of 11 academic medical centers, including data on over 2,500 patients.15                                                                                        1 mo
                                                                                                                60 %
     Patients treated with PSI alone with a D90 of >130 Gy had a PSA relapse-free                                                                                          4 mos
     survival of 93 percent compared with 76 percent for those with lower D90 dose                              40 %
     levels. This review, published in 2007, prompted us to review our data again with                                                                                    10 mos
                                                                                                                20 %
     respect to this specific parameter. Among the 25 patients receiving PSI alone in
     2007, 21 (84 percent) had a D90 >130 Gy. This compares very favorably with a value                                                                                   22 mos
                                                                                                                 0%
     of 45 percent in the national survey.                                                                               <60        60-69        >70         MMC
                                                                                                                        n = 28     n = 139     n = 110      n = 277
     Of the 428 patients treated with prostate brachytherapy, 326 were treated with PSI
     alone	(145	Gy)	and	102	with	PSI	(109	Gy)	plus	45	Gy	EBRT.	Patients	were	treated	by	       PSI + EBRT      100 %
     risk stratification (Table 1). Generally, low-risk patients were treated with PSI alone
                                                                                                                80 %
     while	intermediate-risk	patients	were	treated	with	a	combination	of	PSI	+	EBRT.	                                                                                      1 mos
     Urinary irritation or obstructive symptoms generally worsen in the few months                              60 %
     following the procedure, but begin to improve by four months. By 10 months,                                                                                           4 mos
     80 percent of patients who had pre-treatment AUA scores of 0-7 (mild urinary                               40 %
                                                                                                                                                                          10 mos
     symptoms) have returned to that status (Figure 4). These data are nearly the same
                                                                                                                20 %
     as the QOL data from the NEJM survey of academic prostate cancer referral centers.
                                                                                                                                                                          22 mos
                                                                                                                 0%
     Erectile function data collection began in 2003. We now have 10-month data                                          <60        60-69        >70        MMC
                                                                                                                        n = 16      n = 38      n = 22      n = 86
     on 124 patients treated with PSI alone, in whom the use of hormone therapy
     is infrequent and thus unlikely to confound the results. In this population, 66
     patients (56 percent) had an erection adequate for intercourse (EF 2-3) prior
     to treatment. Nearly all of these (64 of 66) had the same erectile function at 10         the	use	of	temporary	high-dose	rate	implants	in	combination	with	EBRT.17,18,19
     months. Continued data collection is necessary to determine if erectile function is       HDR	is	delivered	remotely	with	a	single	high-dose	moveable	source	(Figure 5).
     maintained at longer follow-up intervals.                                                 This allows for radiation protection of healthcare professionals and family members.
                                                                                               Dose precisely conforms to the treatment volume based on computer planning
     Our PSI results mirror the freedom-from-relapse curves of the Seattle Prostate            by adjusting “dwell times” of the seed along the course of the implanted catheter.
     Institute.16 At 15 years, the data from Seattle show biochemical freedom from             MMC	purchased	and	commissioned	HDR	equipment	in	2005;	it	is	located	in	the	
     relapse of 90 percent, 85 percent, and 60 percent for low-, intermediate-, and high-      Oscar Pluznick Brachytherapy Suite at MMC.
     risk disease, respectively. It is reassuring to note that the curves have plateaued,
     suggesting curable disease.                                                               The	use	of	HDR	in	prostate	cancer	was	still	considered	investigational	by	some	in	
                                                                                               2005. Thus, we elected to gain experience with this modality by participating in a
     High-risk disease remains a treatment challenge in both the radiation and surgical        national	Radiation	Therapy	Oncology	Group	clinical	trial	initially	activated	in	2004,	
     literature. One approach to improve outcomes in this patient population involves          designed to evaluate the toxicity associated with this approach. The patients we


32                                                                                                                                                                                      33
       Quality and Outcomes Report

                                                             Figure 5:                          A subsequent study from Memorial Sloan-Kettering involving over 500 patients
                                                             Shown at top is an idealized       showed	that	the	use	of	IMRT	reduced	the	risk	of	late	rectal	toxicity	to	<2	percent,	
                                                             sagittal and axial view of         while maintaining excellent cancer control.22 As a result of these data, MMC has
                                                             a prostate receiving HDR           invested	fully	in	treatment	machines	and	software	that	allows	delivery	of	IMRT	
                                                             brachytherapy. The prostate
                                                             surrounds the ureter, and the
                                                                                                at all sites of service (Bath, Portland, Scarborough, and Sanford). Image-guided
                                                             catheters are shown in place.      radiation	therapy	(IGRT)	is	used	in	conjunction	with	IMRT	to	more	accurately	
                                                             The “stops” made by the high-      localize	the	target	volume.	Patients	receiving	IGRT	undergo	a	minor	procedure	
                                                             dose radiation source as it        to have three gold fiducial markers placed within the prostate. Immediately prior
                                                             travels in and out of the hollow
                                                             catheters are denoted by
                                                                                                to each treatment, the locations of these seeds are determined while the patient
                                                             small blue circles. Seventy-five   is in the treatment position. A computer-controlled treatment table then adjusts
                                                             percent of the dose remains        the location of the patients, often by just a few millimeters, to center the prostate
                                                             within the dashed blue line.       within the treatment beam. As a result, the volume of normal tissue included in the
                                                             This tightly shaped dose
                                                             spares the bladder and rectum.
                                                                                                treatment field is reduced.
                                                             The dose is also calculated
                                                             and shaped to spare the
                                                             ureter. At bottom is an actual     Adoption of Prostate IGRT
                                                             sagittal and axial view of the     In	2006,	we	began	to	use	IMRT	for	patients	with	prostate	cancer,	based	on	the	
                                                             procedure. The prostate is in
                                                             red, the bladder in yellow, the    data described above. Initially, we used this technology to deliver the same dose
                                                             pubic bone in white, and the       we	had	been	using	with	3D	CRT	more	precisely.	This	in	turn	decreased	toxicity	
                                                             rectum in purple.                  associated with treatment as we gained experience with the newer techniques.
                                                                                                It soon became apparent that we could safely pursue dose escalation once the
                                                                                                techniques	for	IGRT	became	available	at	each	of	our	treatment	sites.	As	a	result,	
     treated on this protocol had very few difficulties. Indeed, the results of the trial,      the	vast	majority	of	patients	with	prostate	cancer	are	now	receiving	IGRT	as	
     presented in late 2008, revealed that less than 3 percent of the 129 patients treated      shown in Figure 6.
     on this protocol had any significant late toxicity.20

     As a result of our experience and the recently published data, we have pursued             Figure 6:                                                                % Total 3D
     this strategy in patients with high-risk prostate cancer, as well as those with            Adoption of Prostate IGRT                                                % Total IGRT
     intermediate-risk and selected patients with low-risk prostate cancer. Through the                                                                                  % Total IMRT
     end of 2007, a total of 63 patients have been treated. The investigational protocol
     stipulated that >90 percent of the target volume receive the dose prescribed. This          100 %
     has been used as the ongoing quality metric, much as the D90 has been used in
     PSI patients. A recent review suggests that this has been achieved in 97 percent of          75 %
     patients.
                                                                                                  50 %
     Several	recent	advances	in	the	techniques	for	delivering	EBRT	for	prostate	
     cancer have also been pursued at MMC, based on data suggesting either
     improved tumor control or reduced toxicity. A randomized trial from the M.D.                 25 %
     Anderson Cancer Center in Houston, involving over 300 patients, showed that
     an	escalation	of	dose	from	70	Gy	to	78	Gy,	using	conventional	3D	CRT,	reduced	                0%
     the risk of cancer recurrence by 25 percent.21 However, there was an associated                        2004           2005           2006           2007            2008
     increase in late rectal toxicity.                                                                                                                                 Jan-Oct


34                                                                                                                                                                                      35
       Quality and Outcomes Report

     The	use	of	EBRT,	via	IMRT	and	IGRT,	is	also	being	reevaluated	at	MMC	in	patients	who	      Medical oncologists are increasingly involved in the management of men with
     have undergone surgical resection but may be at high risk of local recurrence. This        newly diagnosed high-risk prostate cancer. For example, Maine Medical Center
     includes patients with a rising PSA following resection (salvage treatment), as well       recently participated in a national prospective randomized trial evaluating the
     as those who have an undetectable PSA following surgery, but concerning findings           benefits of adjuvant chemotherapy in men with resected high-risk prostate cancer.
     on pathological evaluation (adjuvant treatment). Indeed, two large randomized              This study was closed prematurely because of an unexpectedly high frequency
     trials have shown a reduction in the risk of PSA failure following adjuvant radiation      of acute leukemia in the cohort assigned to chemotherapy.26 Participants in this
     therapy.23, 24 A more recent update of the U.S. trial indicates that the use of adjuvant   study are still being observed for long-term outcomes as it is now still too early to
     radiation therapy reduces recurrence by all parameters measured and improves               determine whether the risks of adjuvant chemotherapy exceed the benefits. Two
     overall survival.25 These trials used conventional techniques available when the trials    other ongoing national prospective clinical trials for the management of men with
     were conducted (in the late 1980s to early 1990s). The use of currently available          newly diagnosed high-risk prostate cancer are currently underway here at Maine
     techniques should offer a similar degree of benefit with less toxicity.                    Medical Center. The primary objective of the first study is to determine whether
                                                                                                treatment with neoadjuvant chemotherapy and androgen deprivation before
                                                                                                radical prostatectomy will improve biochemical progression-free survival at three
     Chemotherapy                                                                               years when compared to treatment with immediate radical prostatectomy alone.
     The Division of Medical Oncology in the Department of Medicine at Maine Medical            The second trial will assess the relative efficacy and toxicity of the combination of
     Center participates actively in the Maine Medical Center Genitourinary Cancer              androgen suppression and radiation therapy followed by androgen suppression
     Program in a number of areas. Medical oncologists are involved in all aspects of           alone versus androgen suppression and radiation therapy followed by androgen
     cancer management, from cancer prevention and screening in populations at risk,            suppression and chemotherapy. Maine Medical Center’s Genitourinary Cancer
     through evaluation and treatment of individual patients with a variety of cancers          Program is committed to providing access to high-quality clinical trials for men
     during many stages of their illness. When appropriate, medical oncologists assume          with clinically localized but high-risk prostate cancer.
     primary care of cancer patients, such as during active chemotherapy and during
     palliative care of end-stage disease. Furthermore, medical oncologists remain central      Medical oncologists often manage men with hormone-resistant prostate cancer.
     to research efforts to develop new and promising strategies for cancer prevention,         Typically, these patients have rising PSA, either alone or with clinically evident
     detection, and management.                                                                 metastatic disease, and have disease progression despite hormone ablation
                                                                                                therapy with gonadotropin-releasing hormone analogs (such as leuprolide).
     These principles apply to prostate cancer, with medical oncologists actively               Treatment options for these patients include the addition and, in some cases,
     participating in efforts to manage prostate cancer at many levels of the problem.          the subsequent withdrawal of one or more antiandrogen agent, corticosteroids,
     For example, medical oncologists participate in the design and conduct of prostate         ketoconazole, and sometimes estrogens. A new secondary hormonal treatment
     cancer clinical trials aimed at prevention and screening in addition to trials aimed       option was recently the subject of significant media attention because of
     at treatment of men with the disease. In southern Maine, we are collaborating in           encouraging results, and we expect that new agent (abiraterone) to enter clinical
     the development and implementation of prostate cancer screening guidelines and             practice during 2009. Many men with hormone-resistant prostate cancer have
     their dissemination among primary care practitioners. Medical oncologists are also         good disease control with these relatively non-toxic therapies for considerable
     directly involved in the care of men with prostate cancer in various ways throughout       periods of time before the development of hormone-refractory prostate cancer.
     their illness. What follows is a brief review of recent, current, and planned aspects of
     medical oncology care for men with prostate cancer.                                        Patients with hormone-refractory prostate cancer are usually cared for by
                                                                                                medical oncologists. These patients are most often men with clinically evident
     Medical oncologists sometimes participate in counseling men with newly diagnosed           progressive disease despite both primary hormone ablation therapy and the
     prostate cancer. Men deemed to be at low- or intermediate-risk from their prostate         secondary hormonal manipulations mentioned above. These individuals are at
     cancer face varied treatment choices that can include watchful waiting, surgery, or        risk for malignancy-related morbidity and mortality from skeletal events, spinal
     radiation therapy. Some patients find it helpful to come to a treatment choice with        cord compression, obstructive uropathy, coagulopathy, and others, as well as from
     assistance from a medical oncologist, in addition to discussions with their urologist      treatment side effects and toxicities. Management strategies, in general, include
     and radiation oncologist.                                                                  supportive care, active intervention with cytotoxic chemotherapy, palliative

36                                                                                                                                                                                      37
       Quality and Outcomes Report

     treatment with radiation therapy, and participation in clinical trials. Skeletal           In summary, medical oncologists participate in all phases of prostate cancer
     problems are frequent in patients with advanced prostate cancer and result                 management, including prevention, screening, and primary treatment, as
     from osteoporosis related to hormone ablation therapy as well as from the direct           well as through treatment of advanced disease. We care for our patients using
     effects of bone metastases. Treatment options include calcium and Vitamin D                evidence-based medicine and national guidelines, and we participate in clinical
     supplementation and the use of bisphosphonates (such as zolidronate) in addition           trials that offer new treatment strategies for our patients as well as progress in
     to radiation therapy and systemic treatments.                                              cancer care for all. Increasingly, medical oncology care for prostate cancer patients
                                                                                                in the Maine Medical Center catchment area is state-of-the-art and equivalent
     In 2004, two prospective randomized clinical trials demonstrated improved survival         to that available in major academic medical centers. Indeed, MMC’s medical
     for patients with metastatic hormone-refractory prostate cancer treated with               oncologists maintain strong ties with colleagues at major centers in Boston and
     docetaxel-based chemotherapy versus prior best available chemotherapy.27, 28               nationally to improve access to novel treatments for our patients here and away
     These trials established a new standard of care for men with late-stage prostate           when appropriate.
     cancer who are able to tolerate cytotoxic chemotherapy. However, the benefits
     of this treatment are limited. The chemotherapy is toxic, and not all patients are
     suitable candidates for treatment. Suitable candidates do not always respond.              Conclusion
     Responders	ultimately	develop	chemotherapy-resistant	disease	and	have	disease	             The Maine Medical Center Prostate Cancer Program provides comprehensive
     progression despite treatment. Currently, there are no standard second-line or             cancer care throughout a patient’s initial evaluation and subsequent management.
     salvage chemotherapy options for men who progress after frontline docetaxel-               We believe that prostate cancer represents a broad spectrum of disease and
     based chemotherapy.                                                                        that this requires a broad and multidisciplinary approach. Whether this involves
                                                                                                questions regarding who should be screened for prostate cancer, or determining
     Research	efforts	are	now	directed	toward	extending	the	benefits	achieved	
                                                                                                the most appropriate management options, we are actively involved in promoting
     with docetaxel chemotherapy. One active strategy is to conduct clinical trials
                                                                                                informed decision making. At MMC, prostate cancer care is individualized with
     evaluating docetaxel-based combination regimens. Another approach is to
                                                                                                the assistance of the Genitourinary Cancer Clinical Patient Navigator, and all
     evaluate new agents in the second-line setting. The Maine Medical Center
                                                                                                patients are provided with the breadth of our multidisciplinary management
     Genitourinary Cancer Program recently participated in one of the prospective
                                                                                                team. For those patients who decide to be treated with definitive therapy, we offer
     randomized trials examining the potential role of a novel agent (a calcitriol
                                                                                                world-class care providers and state-of-the-art equipment. Treatment options
     analog) in addition to docetaxel chemotherapy. Despite promising preliminary
                                                                                                range from low- and high-dose rate brachytherapy, and intensity-modulated and
     results from Phase II trials of the novel combination, this study was closed to
                                                                                                image-guided radiation therapy to laparoscopic/robotic-assisted prostatectomy,
     accrual when an interim analysis suggested that the combination was highly
                                                                                                and prostate cryosurgery to the latest trials in chemotherapy. We are proud of
     unlikely to provide superior outcomes as compared to docetaxel alone. A new
                                                                                                the outstanding care that we provide, and the large number of prostate cancer
     study examining the role of a kinase inhibitor drug in addition to docetaxel is
                                                                                                patients that we have successfully cured with minimal side effects, and believe
     opening at Maine Medical Center in 2009. Similar to the previous trial, this study
                                                                                                that this is exemplified by the outcomes data in this brochure. We hope that this
     is a prospective randomized trial comparing docetaxel alone to docetaxel plus,
                                                                                                Prostate	Cancer	Quality	Report	on	Clinical	Outcomes	will	serve	as	a	resource	for	both	
     the kinase inhibitor in men with hormone-refractory metastatic prostate cancer.
                                                                                                healthcare providers as well as patients navigating the difficult process of deciding
     In recent years, MMC has participated in a clinical trial of a novel agent (satraplatin)
                                                                                                on a management course.
     in the second-line setting for men with hormone- and docetaxel-refractory
     metastatic prostate cancer. That study was completed with some encouraging
     results, but an application for FDA approval of the agent was denied. Additional
     studies of novel agents in the second-line setting are under way nationally, but
     none are available at Maine Medical Center at this time.




38                                                                                                                                                                                       39
       Quality and Outcomes Report

     References
      1.		 Klotz,	L.	“Active	Surveillance	for	Prostate	Cancer:	For	Whom?”	Journal of Clinical Oncology,   16. 	 Sylvester	JE,	et	al.	“15-Year	Biochemical	Relapse	Free	Survival	in	Clinical	Stage	T1-T3	
           23(32):8165-9, 2005.                                                                                 Prostate	Cancer	Following	Combined	External	Beam	Radiotherapy	and	Brachytherapy:	
                                                                                                                The Seattle Experience,” International Journal of Radiation Oncology, Biology, Physics, 67(1):
      2.		 Begg	CB,	et	al.	“Variations	in	Morbidity	after	Radical	Prostatectomy,”	New England Journal
                                                                                                                57-64, 2007.
           of Medicine, 346(15):1138-44, 2002.
                                                                                                          17. 	 Galalae	RM,	et	al.	“Long-Term	Outcome	after	Elective	Irradiation	of	the	Pelvic	Lymphatics	
      3.		 Eastham	JA,	et	al.	“Variations	among	Individual	Surgeons	in	the	Rate	of	Positive	Surgical	
                                                                                                                and	Local	Dose	Escalation	Using	High-Dose-Rate	Brachytherapy	for	locally	advanced	
           Margins	in	Radical	Prostatectomy	Specimens,”	Journal of Urology, 170(6 Pt 1):2292-5,
                                                                                                                Prostate Cancer,” International Journal of Radiation Oncology, Biology, Physics, 52(1):81-90,
           2003.
                                                                                                                2002.
      4.		 Hull	GW,	et	al.	“Cancer	Control	with	Radical	Prostatectomy	Alone	in	1000	Consecutive	
                                                                                                          18. 	 Martinez	AA,	et	al.	“Dose	Escalation	Using	Conformal	High-Dose-Rate	Brachytherapy	
           Patients,” Journal of Urology, 167(2 Pt 1):528-34, 2002.
                                                                                                                Improves Outcome in Unfavorable Prostate Cancer,” International Journal of Radiation
      5. Cheng L, et al. “Preoperative Prediction of Surgical Margin Status in Patients with                    Oncology, Biology, Physics, 53(2):316-27, 2002.
         Prostate	Cancer	Treated	by	Radical	Prostatectomy,”	Journal of Clinical Oncology,
                                                                                                          19.		 Martinez	A,	et	al.	“Conformal	High-Dose-Rate	Brachytherapy	Improves	Biochemical	
         18(15):2862-8, 2000.
                                                                                                                Control and Cause Specific Survival in Patients with Prostate Cancer and Poor
      6.		 Obeck	C,	et	al.	“Positive	Surgical	Margins	with	Radical	Retropubic	Prostatectomy:	                   Prognostic Factors,” Journal of Urology, 169(3):974-80, 2003.
           Anatomic Site-Specific Pathologic Analysis and Impact on Prognosis,” Urology, 54(4):682-
                                                                                                          20. 	 Hsu	I,	et	al.	“Phase	II	Trial	of	Combined	High	Dose	Rate	Brachytherapy	and	External	Beam	
           8, 1999.
                                                                                                                Radiotherapy	for	Adenocarcinoma	of	the	Prostate:	Preliminary	Results	of	RTOG	0321,”	
      7.		 Shekarriz	B,	et	al.	“Intraoperative,	Perioperative	and	Long-term	Complications	of	Radical	           International Journal of Radiation Oncology, Biology, Physics, 72(1):S133, 2008.
           Prostatectomy,” Urologic Clinics of North America, 28(3):639-53, 2001.
                                                                                                          21.		 Kuban	DA,	et	al,	“Long-Term	Results	of	the	M.D.	Anderson	Randomized	Dose-Escalation	
      8. Partin AW, et al. “Combination of Prostate-Specific Antigen, Clinical Stage, and Gleason               Trial for Prostate Cancer,” International Journal of Radiation Oncology, Biology, Physics,
         Score to Predict Pathological Stage of Localized Prostate Cancer: A Multi-Institutional                70(1):67-74, 2008.
         Update,” Journal of the American Medical Association, 277(18):445-51, 1997.
                                                                                                          22.		 Zelefsky	MJ,	et	al.	“Long-Term	Outcome	of	High	Dose	Intensity	Modulated	Radiation	
      9.		 Stock	RG,	et	al.	“Sexual	Potency	Following	Interactive	Ultrasound-Guided	Brachytherapy	              Therapy for Patients with Clinically Localized Prostate Cancer,” Journal of Urology, 176(4
           for Prostate Cancer,” International Journal of Radiation Oncology, Biology, Physics,                 Pt 1):1415-9, 2006.
           35(2):267-72, 1996.
                                                                                                          23.		 Bolla	M,	et	al.	“Postoperative	Radiotherapy	after	Radical	Prostatectomy:	A	Randomized	
     10.		 Stock	RG,	et	al.	“Penile	Erection	after	Permanent	Radioactive	Seed	Implantation	for	                 Controlled	Trial	(EORTC	trial	22911),”	Lancet, 366(9485), 2005.
           Treatment of Prostate Cancer,” Journal of Urology, 165(2):436-9, 2001.
                                                                                                          24.		 Thompson	IM	Jr,	et	al.	“Adjuvant	Radiotherapy	for	Pathologically	Advanced	Prostate	
     11. Sanda MG, et al. “Quality of Life and Satisfaction with Outcome among Prostate-Cancer                  Cancer:	A	Randomized	Clinical	Trial,”	Journal of the American Medical Association,
         Survivors,” New England Journal of Medicine, 358(12):1250-61, 2008.                                    296(19):2329-35, 2006.
     12. Cohen JK, et al. “Ten-Year Biochemical Disease Control for Patients with Prostate Cancer         25.		 Thompson	Ian,	et	al.	“Adjuvant	Radiotherapy	for	Pathological	T3N0M0	Prostate	Cancer	
         Treated with Cryosurgery as Primary Therapy,” Urology, 71(3):515-8, 2008.                              Significantly	Reduces	Risk	of	Metastases	and	Improves	Survival:	Long-Term	Followup	of	
     13. www.seattleprostateinst.com                                                                            a	Randomized	Clinical	Trial,”	Journal	of	Urology,	181:956-62,	2009.	

     14.		 Cox	JD,	et	al.	“Consensus	Statement:	Guidelines	for	PSA	Following	Radiation	Therapy:	          26.		 Flaig	TW,	et	al.	“Randomization	Reveals	Unexpected	Acute	Leukemias	in	Southwest	
           American	Society	for	Therapeutic	Radiology	and	Oncology	Consensus	Panel,”	                           Oncology Group Prostate Cancer Trial,” Journal of Clinical Oncology, 26(9):1532-6, 2008.
           International Journal of Radiation Oncology, Biology, Physics, 37(5):1035-41, 1997.            27. Tannock IF, et al. “Docetaxel Plus Prednisone or Mitoxantrone Plus Prednisone for
     15. Zelefsky MJ, et al. “Multi-Institutional Analysis of Long-Term Outcome for Stages T1-T2              Advanced Prostate Cancer,” New England Journal of Medicine, 351(15):1502-12, 2004.
         Prostate Cancer Treated with Permanent Seed Implantation,” International Journal of              28. Petrylak DP, et al. “Docetaxel and Estramustine Compared with Mitoxantrone and
         Radiation Oncology, Biology, Physics, 67(2):327-33, 2007.                                            Prednisone	for	Advanced	Refractory	Prostate	Cancer,”	New England Journal of Medicine,
                                                                                                              351(15):1513-20, 2004.
40                                                                                                                                                                                                               41
                     The Maine Medical Center Cancer Institute proudly works with our colleagues at
                     Maine Medical Partners, Maine’s largest multi-specialty medical group, to serve
                     the healthcare needs of patients throughout northern New England.

                                        Moritz Hansen, MD
                                        Medical Director, Maine Medical Center Cancer Institute Genitourinary
                                        Cancer Program
                                        Urologic Surgeon, Maine Medical Partners – Urology
                                        Medical School: College of Physicians & Surgeons, Columbia University,
                                        New York, NY
                                        Advanced Training: Stanford University Medical Center (general surgery
                                        and	urologic	surgery	residencies),	Rockefeller	University	(medical	research	
                                        fellowship)
                                        Board Certification: Urology
                                        Specialty Interests: Prostate cancer clinical outcomes research, robotic and
                                        laparoscopic surgery, bladder cancer continent urinary diversion (neobladder)


                                        Craig Hawkins, MD, FACS
                                        Urologic Surgeon, Maine Medical Partners – Urology
                                        Medical School: University of Vermont College of Medicine
     Staff Listing                      Advanced Training: Yale School of Medicine (general surgery and urology
                                        residencies), Mayo Clinic and Graduate School of Medicine (urologic
                                        oncology fellowship)
                                        Board Certification: Urology
                                        Specialty Interests: Bladder cancer clinical outcomes research, bladder
                                        cancer continent urinary diversion (neobladder), prostate cryosurgery


                                        Thomas Kinkead, MD
                                        Urologic Surgeon, Maine Medical Partners – Urology
                                        Medical School: University of Vermont College of Medicine
                                        Advanced Training: University of Massachusetts Medical Center (general
                                        surgery and urology residencies), Hospital for Sick Children, Great Ormond
                                        Street, London, UK (pediatric urology fellowship)
                                        Board Certification: Urology
                                        Specialty Interests: Adult and pediatric urology, robotic and
                                        laparoscopic surgery


                                        Lisa Tran Beaule, MD
                                        Urologic Surgeon, Maine Medical Partners – Urology
                                        Medical School: University of Vermont College of Medicine
                                        Advanced Training: Massachusetts General Hospital (general surgery
                                        residency), Lahey Clinic (urologic surgery residency), Children’s Hospital, Boston
                                        (medical research fellowship)
                                        Board Certification: Urology
                                        Specialty Interests:	Robotic	and	laparoscopic	surgery
42                                                                                                                           43
     The Maine Medical Center Cancer Institute is proudly partnered with Spectrum                                 Rodger Pryzant, MD
     Medical Group. Spectrum is Maine’s most comprehensive, privately owned                                       Radiation Oncologist, Maine Medical Center Cancer Institute Division of
     group of fellowship trained physicians with expertise in Radiation Oncology,                                 Radiation Oncology
     Pathology, Radiology, Interventional and Vascular services, Pain Management,                                 Radiation Oncologist, Spectrum Medical Group
     and Anesthesiology.                                                                                          Medical School: Baylor College of Medicine, Houston, TX
                                                                                                                  Advanced Training: Baylor College of Medicine (radiation oncology
                        Cornelius McGinn, MD                                                                      residency), M.D. Anderson Cancer Center, Houston, TX (radiation oncology
                                                                                                                  residency, clinical oncology fellowship)
                        Medical Director, Maine Medical Center Cancer Institute Division of
                        Radiation Oncology                                                                        Board Certification: Radiation	Oncology
                        Radiation Oncologist, Spectrum Medical Group                                              Specialty Interests: Prostate	HDR	brachytherapy,	prostate	seed	
                                                                                                                  implantation,	IMRT/IGRT,	prostate	cancer	clinical	outcomes	research
                        Medical School: University of Vermont College of Medicine
                        Advanced Training: University of Wisconsin Hospital, Madison, WI
                        (radiation oncology residency)
                        Board Certification: Radiation	Oncology                                                   Philip Villiotte, MD
                        Specialty Interests: Prostate	seed	implantation,	IMRT/IGRT,	prostate	                     Radiation Oncologist, Maine Medical Center Cancer Institute Division of
                        cancer clinical outcomes research                                                         Radiation Oncology
                                                                                                                  Radiation Oncologist, Spectrum Medical Group
                                                                                                                  Medical School: Dartmouth Medical School, Hanover, NH
                        Ian Bristol, MD                                                                           Advanced Training: Duke University Medical Center, Durham, NC
                        Radiation Oncologist, Maine Medical Center Cancer Institute Division of                   (radiation oncology residency)
                        Radiation Oncology                                                                        Board Certification:	Radiation	Oncology
                        Radiation Oncologist, Spectrum Medical Group                                              Specialty Interests:	IMRT/IGRT,	brachytherapy
                        Medical School: University	of	Rochester	School	of	Medicine,	New	York
                        Advanced Training: M.D. Anderson Cancer Center, Houston, TX (radiation
                        oncology residency)
                        Board Certification:	Radiation	Oncology
                        Specialty Interests:	IMRT/IGRT,	stereotactic	radiosurgery,	brachytherapy   Other Staff Listing


                        Michael Jones, MD                                                                         Frederick Aronson, MD, MPH
                        Chief, Department of Pathology and Laboratory Medicine,                                   Director, Maine Medical Center Cancer Institute Division of Medical Oncology
                        Maine Medical Center                                                                      Medical Oncologist, Maine Center for Cancer Medicine
                        Pathologist, Spectrum Medical Group                                                       Medical School: Yale University School of Medicine
                        Medical School: University of Cincinnati College of Medicine,                             Advanced Training: Rhode	Island	Hospital	(internal	medicine	residency),	
                        Cincinnati, OH                                                                            Tufts University – New England Medical Center (hematology-oncology
                        Advanced Training: Medical Center Hospital of Vermont, University of                      fellowship)
                        Vermont (residency)                                                                       Board Certification: Internal medicine, medical oncology, hematology
                        Massachusetts General Hospital (Gynecologic and Urologic Pathology                        Specialty Interests:	Research	in	tumor	and	cellular	immunology,	cytokine	
                        fellowship), Boston, MA                                                                   biology, vascular biology, malignant lymphoproliferative diseases,
                        Yale-New Haven Hospital (Surgical Pathology/Cytology fellowship), New                     cutaneous and genitourinary malignancies, gene therapy, clinical trials
                        Haven, CT
                        Board Certification: Board of Pathology, Anatomic and Clinical Pathology
                        Specialty Interests: Gynecologic pathology, pediatric solid tumors,
                        endocrine pathology, breast pathology urologic pathology, cytology


44                                                                                                                                                                                               45
                           Clinical Research

                         Clinical trials and bench research are vital to improving patient care for prostate
                         cancer. Today’s research identifies new drugs, treatments, and diagnostic tools for
                         tomorrow.	Through	MMC’s	research	initiatives	and	connections	with	its	Research	
                         Institute	(MMCRI)	and	the	Maine	Center	for	Cancer	Medicine,	cancer	patients	in	
                         Maine have access to the same clinical trials offered at major cancer centers across
                         the nation.

                         In	addition,	the	Maine	Medical	Center	Research	Institute	in	Scarborough	has	received	
                         substantial federal support for biomedical research and serves as a catalyst for
                         economic	and	academic	growth	in	the	region.	MMCRI	is	one	of	the	most	innovative	
                         research organizations in the nation and is Maine’s largest hospital-based research
                         center. It also is the only non-university entity in the nation to receive two Center of
                         Biomedical	Research	Excellence	awards	from	the	National	Institutes	of	Health.			

                         Maine	Medical	Center’s	Research	Institute	maintains	an	Institutional	Review	Board	
                         (IRB)	to	oversee	the	protection	of	those	who	are	enrolled	in	a	clinical	study.	The	IRB	
                         ensures that each study meets established ethical principles and complies with
                         federal and state regulations, as well as other guidelines related to the protection of
                         human	subjects.	The	IRB	currently	monitors	about	250	clinical	trials	that	are	providing	
                         state-of-the-art care to approximately 3,000 patients. At this time, one quarter of
     Clinical Research   clinical trials are cancer-related and have a scope that spans the entire continuum of
                         care – from prevention to follow-up.

                         Calvin	Vary,	Ph.D.,	a	researcher	at	MMCRI,	is	studying	prostate	cancer	metastasis,	
                         the primary cause of mortality associated with this disease. His lab has developed a
                         model of prostate cancer metastasis that can genetically manipulate components
                         of the transforming growth factor beta (TGF-beta) signaling pathway to influence
                         the development of metastatic prostate cancer in male mice. Identifying the
                         components in the TFG-beta signaling pathway that lead to metastatic prostate
                         cancer holds promise for developing novel therapeutic approaches to block this
                         process and thus improve prostate cancer survival.

                         Tomorrow’s cures will be identified and tested at institutions such as ours. Scientists
                         and doctors at Maine Medical Center are unlocking many of the mysteries
                         surrounding cancer prevention, diagnosis, and care, and we are working hard to
                         bring that knowledge to patients as quickly as possible.




46                                                                                                                  47
                                                                Other Patient & Family Support & Educational Resources

                                                              American Cancer Society Patient Navigator
                                                              While MMC’s Clinical Patient Navigator helps guide patients through the clinical
                                                              decision-making process, we also have a Patient Navigator who is available to help
                                                              patients navigate the myriad community support resources available as part of the
                                                              cancer care process. This, too, is the first oncology position of its kind in Maine.

                                                              Trained through a special American Cancer Society (ACS) program, the Patient Navigator
                                                              helps guide patients through the cancer care system and links them to appropriate
                                                              programs and resources. Typical issues the Patient Navigator might address include:

                                                                •	 Language	or	cultural	barriers	      •	 Insurance	difficulties	
                                                                •	 Transportation	                     •	 Access	to	support	groups	or	classes	
                                                                •	 Lack	of	financial	resources	        •	 Links	to	home	health,	respite	care,	or	hospice

                                                              This ACS Patient Navigator is based out of the Maine Medical Center Cancer Institute
                                                              in Scarborough.

                                                              For more information or to refer a patient, please contact Heather Ciccarelli, LSW,
                                                              at (207) 885-8335.
     Other Patient & Family Support & Educational Resources
                                                              Community Education
                                                              MaineHealth Learning Resource Centers
                                                              The	MaineHealth	Learning	Resource	Centers	(LRC)	offer	an	array	of	community	
                                                              health education programs, classes, and seminars to patients and families. There
                                                              are	three	LRCs	in	the	greater	Portland	area,	and	each	center	has	an	extensive	library	
                                                              of books, periodicals, videos, and DVDs on a wide variety of healthcare topics.
                                                              Computers with Internet access are also available, along with hands-on orientation
                                                              to research health information. In addition, professional educators are always present
                                                              to assist patients with their health information needs.

                                                              The	Maine	Health	Learning	Resource	Center,	specializing	in	cancer,	is	located	at:

                                                              100 Campus Drive, Suite 106
                                                              Scarborough, ME 04074

                                                              Hours: Monday – Friday, 8:30 a.m. – 5:00 p.m.
                                                              Phone: (207) 885-8570
                                                              Fax: (207) 885-7969

                                                              In addition, Maine Medical Center has a strong network of local, state, and national
                                                              resources to help patients and families navigate the cancer journey. For more
                                                              information, please call (207) 885-8570.
48                                                                                                                                                         49
       Other Patient & Family Support & Educational Resources

     Cancer Risk and Prevention Clinic                                                         Home and Hospice Care
     MMCCI’s	Cancer	Risk	and	Prevention	Clinic	is	an	outpatient	service	that	gives	            When dealing with cancer, many patients prefer comfortable and familiar
     primary care physicians and patients state-of-the-art risk assessment resources,          surroundings of their own home. The home healthcare agencies of MaineHealth
     particularly for familial/hereditary risk and preventive strategies. Through risk         (Maine Medical Center’s parent organization) offer a full range of services to assist
     assessment, genetic counseling, and genetic testing, we help identify those at            patients and their families, including skilled and supportive nursing services,
     increased risk and provide guidance to help physicians care for their patients.           rehabilitation and social work therapies, community education, parent and child
                                                                                               health support, and hospice care.
     For	more	information	or	to	make	a	referral	to	the	Cancer	Risk	and	Prevention	Clinic	
     at MMCCI, please contact:                                                                 For home health and hospice care in York, Cumberland, Oxford, Androscoggin, and
                                                                                               Sagadahoc counties, please contact:
     MMCCI	Cancer	Risk	and	Prevention	Clinic
     100 Campus Drive, Suite 110                                                               HomeHealth – Visiting Nurses of Southern Maine
     Scarborough, ME 04074                                                                     15	Industrial	Park	Road
     (207) 885-7787                                                                            Saco, Maine 04072
                                                                                               (207) 775-5515
                                                                                               www.homehealth.org
     Screening Programs
     Physicians and staff from Maine Medical Partners – Urology, MMC – Division of
     Radiation	Oncology,	MMC	Scarborough	Surgery	Center,	and	Spectrum	Medical	                 Clinical Oncology Social Work
     Group sponsor free screening programs.                                                    Helping patients and families cope with the stress related to a cancer diagnosis
                                                                                               is one of the most important services our oncology social workers can provide.
     For more information about free screening programs, please call (207) 885-8570.           MMCCI’s social workers are Masters level, trained, and licensed clinical social
                                                                                               workers who specialize in working with people with cancer. Our social workers
                                                                                               are available to all patients receiving outpatient care and are available to patients
     Palliative Care
                                                                                               and families throughout all phases of the cancer experience. From prevention to
     Palliative care eases the suffering of the advanced illness, providing treatment for
                                                                                               diagnosis, treatment to survivorship – we’re here to help.
     a patient’s symptoms even when the underlying disease cannot be cured. MMC’s
     Pain and Palliative Care team is made up of experts in care related to symptom            Services provided by the oncology social worker include:
     management, and works with physicians and primary care teams to help meet
     patients’ needs.                                                                            •	 Psychosocial	needs	assessments	to	assist	the	person	with	cancer	and	his/her	family	
                                                                                                    members’ spiritual and emotional needs and to plan interventions accordingly.
     If you have a patient who would benefit from palliative care, please make a referral        •	 Counseling	for	patients	and	family	members	to	promote	optimal	emotional	health	and	
     to the Center for Pain and Palliative Care. A physician or nurse practitioner will meet        coping. Counseling can address issues such as depression, anxiety, stress, and effects on
     with your patient and help determine what resources would be most helpful.                     family and relationships.

     Maine Medical Center                                                                        •	 Teaching	patients	how	to	work	with	the	mind/body/spirit	connection.	For	example,	
     Center for Pain and Palliative Care                                                            teaching stress management and relaxation techniques, guided imagery, and meditation.
     22	Bramhall	Street,	Room	4670                                                               •	 Support	and	education	for	parents	of	children	or	grandchildren.	Support	children	when	a	
     Portland, ME 04102                                                                             parent/grandparent has cancer, connecting with community resources for children.
     (207) 662-3500
                                                                                               If your patient is interested in or could benefit from speaking to a clinical social
                                                                                               worker, call Trisha Warren-VanHorn, LCSW, MSW, at (207) 885-8565.


50                                                                                                                                                                                              51
       Other Patient & Family Support & Educational Resources

     Nutrition Services                                                                       Support Groups
     Maintaining good nutritional status during cancer treatment is essential to a            Maine Medical Center’s Cancer Institute partners with the Cancer Community
     positive outcome. Cancer treatments, such as surgery, chemotherapy, and radiation        Center to offer a variety of support and networking groups, lectures, workshops,
     can cause side effects that may impact a patient’s ability to eat.                       and social events each month to address the concerns of patients, families, and
                                                                                              caregivers dealing with specific types of cancer. Together we offer a comfortable,
     The right nutrition plan can optimize the immune system, help minimize treatment         friendly place where all can gather to build social and emotional support as a
     breaks, and enhance a patient’s quality of life. Patients with good nutrition may also   complement to regular medical care. All events are free of charge.
     tolerate higher doses of certain treatments and better cope with treatment side
     effects. Since each patient is different, the Maine Medical Center Cancer Institute      For more information, contact the Cancer Community Center at (207) 774-2200
     has dedicated a registered dietitian to work with each patient to meet their             or the MMC Social Work Department at (207) 662-2261.
     individual needs.

     A registered dietitian is a healthcare professional licensed by the state to offer       Transportation
     counseling on achieving and maintaining optimal nutrition and to better                  For some patients undergoing cancer treatment, getting to and from
     withstand the rigors of cancer treatment. A registered dietician must complete           appointments can pose a real hardship. The Patient Navigator can provide
     a comprehensive educational curriculum approved by the American Dietetic                 information about and assistance with all patient transportation needs.
     Association.
                                                                                              For more information, please contact our Patient Navigator, Heather Ciccarelli, LSW,
     For more information about these services, please contact MMC Cancer Institute           at (207) 885-8335.
     Clinical	Oncology	Dietitian,	Karen	Schilling,	MS,	RD,	LD,	at	(207)	885-8524.	

                                                                                              Interpreter Services
                                                                                              For patients who do not speak English, MMC offers free interpreter services.
                                                                                              Medical interpreters are available at all times to help ensure that patients and
                                                                                              families get all their questions answered and information is understood.

                                                                                              For more information, call (207) 662-4983.




52                                                                                                                                                                                   53
                                                          Key Outpatient Locations and Contact Information

                                                        MMC Cancer Institute Genitourinary Cancer Program
                                                        Key Outpatient Locations and Contact Information
                                                        The Maine Medical Center Cancer Institute’s outpatient cancer services are
                                                        centralized	at	MMC’s	Scarborough	Campus,	100	Campus	Drive,	right	off	US	Route	1.	
                                                        Among the genitourinary-related resources available here are:

                                                        MMC Cancer Institute
                                                        Main administrative number: (207) 885-7690

                                                        Clinical Patient Navigator for Genitourinary Cancer
                                                        (207) 885-8439

                                                        MMCCI Diagnostic Center
                                                        Offers a full range of radiology imaging services, with board-certified radiologists
                                                        on-site to interpret and oversee the imaging evaluations.
                                                        (207) 885-7750

                                                        MMCCI Outpatient IV Therapy
                                                        (207) 885-7705

     Key Outpatient Locations and Contact Information   MMCCI Cancer Risk and Prevention Clinic
                                                        (207) 885-7787

                                                        MMCCI Radiation Oncology
                                                        (207) 885-7500

                                                        Radiation	oncology	services	are	also	available	at	the	following	centers:

                                                           Coastal Cancer Treatment Center
                                                           175 Congress Avenue, Bath
                                                           (207) 443-5866

                                                           Southern Maine Radiation Therapy Institutue at Maine Medical Center
                                                           22 Bramhall Street, Portland
                                                           (207) 662-2276

                                                           Cancer Care Center of York County
                                                           27 Industrial Avenue, Sanford
                                                           (207) 459-1600




54                                                                                                                                             55
       Key Outpatient Locations and Contact Information

     Also located at the Scarborough Campus:

     Maine Center for Cancer Medicine
     A private medical group practice composed of oncologists and hematologists.
     (207) 885-7600


     MMC and affiliated practices and services at other locations:

     MMC Center for Pain and Palliative Care
     22	Bramhall	Street,	Room	4670
     Portland, ME 04102
     (207) 662-3500

     Maine Medical Partners – Urology
     Maine’s largest group of board-certified urologists with expertise in all facets of
     urologic surgery and the medical management of urologic disease.

     100 Brickhill Avenue
     South Portland, ME 04106
     (207) 773-1728
                                                                                           How to Refer a Patient
     Cancer Care Center of York County
     A collaboration of Maine Medical Center, Goodall Hospital, and Southern Maine
     Medical Center, the Center is staffed by oncologists from Spectrum Medical
     Group and the Maine Center for Cancer Medicine, and provides a range of cancer
     treatment and support services.

     27 Industrial Avenue
     Sanford, ME 04073
     (207) 459-1600




56                                                                                                                  57
       How to Refer a Patient

     Maine Medical Center Cancer Institute                                           Notes
     Genitourinary Cancer Program

     For surgical urological care referrals, call Maine Medical Partners — Urology

     (207) 773-1728
     For radiation oncology referrals, call MMCCI Radiation Oncology

     (207) 662-6244
     For questions or concerns about genitourinary cancer, or to schedule a second
     opinion,	please	contact	Jennifer	Powers,	MS,	BSN,	RN,	CCRC,	Monday	through	
     Friday, 8:30 a.m. to 5 p.m. at (207) 885-8439.




58
MMC Cancer Institute
100 Campus Drive, Suite 102
Scarborough, ME 04074
www.mmc.org

								
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