Bringing PCPs “back” Into Cancer Care Through Onco-Primary
Against the GrainBringing PCPs “back” into CancerCare through Onco-Primary CareKevin C. Oeffinger, MDDirector, Duke Center for Onco-Primary CareProfessor with TenureDepartment of MedicineSecondary: Department of Community & Family MedicineDuke Community & Family Medicine GrandRoundsJune 18, 2018
Outline Cancer continuum (screening, prevention,cancer care, survivorship)– Current care model in U.S.– Onco-primary care model Duke Center for Onco-Primary Care(T 13 months)
Cancer ContinuumPreventionScreeningPeople in the U.S., 2016330 M310 MCancer TherapySurvivorship2016 Model2026 Model Prevention PreventionoooLifestyle(Chemoprevention)(Genetics) ScreeningOne-size fits allo Cervicalo Breasto Colono Prostateo Lungo151 M1.6 M1.1 M SurvivorshipoOne-size fits allLifestyleo Targeted chemopreventiono Population geneticso ScreeningRisk-stratifiedo Tumor biomarkerso Expanded cancerso SurvivorshipRisk-stratifiedo Efficient utilization ofresourceso Coordinated careo
Advances in Cancer Screening
‘Screenable’ Cancers in the U.S.CancerCases/yr % of .3%47.4%% ofdeaths6.8%8.3%0.7%4.4%26.5%46.7%
‘Screenable’ Cancers in the U.S.CancerCases/yr % of .3%47.4%% 46%80%16%
‘Screenable’ Cancers in the U.S.CancerCases/yr % of total% tal 134,4908.0%8.3%39%Key points:Cervical12,9900.8%can potentially0.7% be detected46% Almost 50%of cancer casesProstate10.7%4.4%80%by current180,890screening tests These cancersaccount13.3%for about 50%of cancer 16%deathsLung224,39026.5% Substantial % of cancers detected at advanced stageTotal47.4%46.7% Though not all screen-detected cancers can be cured,we can do MUCH better
U.S. Cancer Screening Rates10090Percent80706050403020100Cervical BreastColon ProstateLungSmith RA, et al. CA Cancer J Clin, 2017
Siu AL, et al. Ann Intern Med, 2016How does awoman age 40-49make aninformed decisionon breast cancerscreening?Oeffinger KC, et al. JAMA, 2015
If we take 1,000 womenat the age of 40and follow themfor 5 years withan annual mammogram6 in1000954in100050 in1000
If we take 1,000 womenat the age of 40and follow themfor 5 years withan annual mammogram6 in1000954in100050 in1000Family History andBreast Density6 12/1,0006 1/1,000BRCA1 carrier6 80/1,0001/12
Risk-Stratified Cancer ScreeningIf we take 1,000 womenat the age of 40and follow themfor 5 years withan annual mammogram6 in1000954in100050 in1000Family History andBreast Density6 12/1,0006 1/1,000BRCA1 carrier6 80/1,0001/12
No significant difference in prostate cancerdeaths between two groups.However, 90% of control group hadundergone PSA testing.
20% reduction in prostate-specific mortalityRate ratio 0.80 (95% CI 0.65-0.98)
Moyer VA, et al. Ann Intern Med, 2012
USPSTF, JAMA 2018
Negoita S, et al. Cancer, 2018
Prostate Cancer Screening
Duke Primary Care PSA Screening Algorithm
CountyDuke Primary Care andDuke Primary Care Consortium224 primary care physicians34 practice sites7 countiesExpanding sites and physiciansAll on same EHR (Epic)Existing research infrastructure(PBRN)DurhamPracticeDPC Pickett RoadDPC CroadaileDUC CroasdaileDUC Fayetteville RoadDurham Medical CenterDurham Pediatrics – MainSutton Station Internal MedicineTriangle Family PracticeGranvilleDPC Butner-CreedmoorOxford Family PhysiciansVanceDPC HendersonAlamanceDPC MebaneKernodle Clinic WestChathamDPC of Galloway RidgeOrangeDPC HillsboroughDUC HillsboroughDPC MeadowmontDPC TimberlyneWakeDPC ApexDPC Blue RidgeDPC Brier CreekDPC Creedmoor RoadDPC MidtownDPC KnightdaleDPC MorrisvilleDPC Waverly PlaceDPC WellesleyDPC Western WakeDPC Wake ForestDPC Wakelon Internal MedicineDUC Brier CreekDUC KnightdaleDUC MorrisvilleNorth Hills Internal Medicine
Duke Primary Care PSA Screening Algorithm
Duke Primary Care PSA Screening Algorithm
Implementation Resulted in Increased ScreeningPercentChange in PSA Testing Pre-Post February 22, 2017100%90%80%70%60%50%40%30%20%10%0%70%48%PSA PresentPreCourtesy of Kevin Shah, MDPost
Screening increased in all clinics,but rates of screening by clinic vary widelyCourtesy of Kevin Shah, MD
Urology ReferralsFebruary 22, 2017 – February 21, 2018Age Group 40 yrs40-49AlgorithmDo not screen70-75Totals%2919.0%Resume screening at 503,4211524.4%Screen q 3336.7%Screen q 2 en q 2 yrsRefer76 UrologyReferrals153Refer50-69PSAsDo not screen
Urology ReferralsFebruary 22, 2017 – February 21, 2018Age Group 40 yrs40-49AlgorithmDo not screen70-75Totals%2919.0%Resume screening at 503,4211524.4%Screen q 3336.7%Screen q 2 en q 2 yrsRefer76 UrologyReferrals153Refer50-69PSAsDo not screen
Urology ReferralsFebruary 22, 2017 – February 21, 2018Age Group 40 yrs40-49AlgorithmDo not screen70-75Totals%2919.0%Resume screening at 503,4211524.4%Screen q 3336.7%Screen q 2 en q 2 yrsRefer76 UrologyReferrals153Refer50-69PSAsDo not screen
Key Lessons Rapid uptake using Epic with algorithmembedded in health maintenance / labresults Substantial variation in practice Under and over referrals Need for efficient and effective informeddecision tool
Decision Aid Development and pilot testing of a CDCsupported patient decision aid for prostate cancerscreening. Led by John Ragsdale, MD and Sharon Hull, MD
Potential Approaches to Help PCP level approaches– Adding Prostate Health Index (PHI) reflex– Role of Digital Rectal Exams– Alternative referral pathways Patient-level approaches– Pre-visit video vignettes via MyChart– Decision aid with visit (upcoming pilot test in 3 sites)– Improved lab result messaging within Epic System-level approaches––––Nurse navigator (DCI-DPC liaison)Better tracking of screening to referral to scheduled appointmentMulti-disciplinary quality improvement teamPrimary care physician participation in GU oncology tumor board
Chemoprevention - 2017Uptake of SERMs for chemoprevention in clinical practiceSmith SG, et al. Ann Oncol, 2016
Precision Screening and Chemoprevention ‘Liquid biopsy’– circulating cell-free DNA (cfDNA)– circulating tumor cells (CTC)Vockley JG and Niederhuber JE. BMJ, 2015Meyskens FL, et al. J Natl Cancer Inst, 2016Albini A, et al. Clin Cancer Res, 2016 Epigenetic-marker based system with detectionrate of breast cancer similar to mammographyUehiro N, et al. Breast Ca Res, 2016 Cancer interceptionExample: ErbB2 inhibition and lapatinibLi D, et al. Oncotarget, 2017
Importance of Non-Cancer ComorbiditiesProbability of death from breast cancer or othercauses among women age 50 and olderwith ER early stage breast cancerSEER: 1988-2001Percent of women withearly stage breast cancerand a cardiovascular risk factorSEER-Medicare: 2000-2007100Percent806040200HTNHanrahan EO, et al. J Clin Oncol, 2007Bradshaw PT, et al. Epidem, 2016LipidsDMChen J, et al. J Am Coll Cardiol, 2012
Percent of breast cancer survivors adherent to their statin therapy priorto and following early stage breast cancer diagnosis and treatment(Group Health 1990-2008, N 4,221 women)1009080Percent706050403020100Year - 1TreatmentperiodYear 1Year 2Year 3Calip GS, et al. Breast Cancer Res Treat, 2013Presented by: Kevin C. Oeffinger, MD
Predictors of nonadherence to medicationsamong breast cancer survivors(Group Health 1990-2008, N 2,308)Calip GS, et al. Breast Cancer Res Treat, 2017Presented by: Kevin C. Oeffinger, MD
Importance of Non-Cancer Comorbidities Most women with breast cancer will not die ofbreast cancer Continued monitoring and management ofcommon comorbidities may be as important forlongevity / QoL as treatment of the breast cancer Lack of standardized approaches to managehypertension, diabetes, and lipid disorders
Management of Comorbidities Hypertension (pre/during/post cancer) is a keyrisk factor in development of heart failure incancer survivors treated with cardiotoxic therapy– Jawa Z, et al. Medicine, 2016– Chen J, et al. J Am Coll Cardiol, 2012– Salz T, et al. J Clin Oncol, 2017 Studies pre new AHA / ACC guidelines for HTN 120 / 80 To date, no intervention studies aimed at bloodpressure management during / after cancertherapy Other comorbidities associated with an increasedrisk of poor outcomes
47-year-old breast cancer survivor Diagnosed at age 42 Invasive ductal carcinoma ER- PR- HER2 T2N1 Trastuzumab 50 Gy to Right breast150100506/136/146/156/166/18
47-year-old breast cancer survivor Diagnosed at age 42 Invasive ductal carcinoma ER- PR- HER2 T2N1 Trastuzumab 50 Gy to Right breastLipid profile Total 247 LDL 188 HDL 51 TG 40Statin therapy?10-year risk 1.8%
Chronic Cancer Patient Increasing number of patients withadvanced cancer are now being treatedas chronic cancer patients Management of comorbidities remainsessential in this population ‘Cure the cancer, lose the patient’
Future Study Randomized controlled trial Population: Breast and prostate cancer patients receivingcardiotoxic therapy Primary outcome – blood pressure control Intervention: automated text alert to patient and Epicmessage to PCP when BP is above threshold Control – usual care Team: oncology, cardiology, primary care, populationhealth science, biostatistics, onco-primary care Overarching goals:– Blood pressure management and prevention of cardiotoxicity– Re-engage PCPs in the care of patients on therapy
Cancer Survivors in the United StatesThere are now 14.5 million survivors in the USBy 2020, there will be almost 18 million survivorsDe Moor JS, et al. Cancer Epidemiol Biomarkers Prev, 2013
Late Mortality Among 5 Year SurvivorsChildhood Cancer Survivor Study (N 20,483)CausesSecond cancersCardiacPulmonarySMR15.27.08.8Mertens AC, et al. J Natl Cancer Inst, 2009
Cumulative Cause-Specific MortalityChildhood Cancer Survivor StudyArmstrong GT, et al. J Clin Oncol, 2009
Late Mortality Among 5 Year HL SurvivorsMSKCC Hodgkin Lymphoma Study (1975-2000; N 747)Matasar M, et al. J Natl Cancer Inst, 2015
Cumulative Incidence by Causes of Death for Patients WithStage I Testicular SeminomaSEER Registry: N 9193 men; Diagnosed 1973-2001Beard CJ, et al. Cancer 2013
Probability of death from breast cancer or other causesamong women age 50 and olderwith ER early stage breast cancerSEER: 1988-2001Hanrahan EO, et al. J Clin Oncol, 2007
Cumulative incidence of chronic physical health conditionsamong 10,397 young adult survivors of childhood cancerChildhood Cancer Survivor Study1Cumulative Incidence0.973.4% with at least onechronic condition0.80.70.642.4% with a severe orlife-threateningcondition or death0.50.40.30.20.10051015202530Years since CancerOeffinger KC, et al. N Engl J Med, 2006
Morbidity following Adult Cancer To date, some studies looking at specificoutcomes (SMN, cardiac) in specific cancerpopulations (Hodgkin lymphoma, testicularcancer) No overall estimates of morbidity U-shaped curve by age?oooYounger age: developing organsMid-age: interaction of therapy with comorbidhealth conditionsOlder age: senescent organs
SystemExposuresPotential Late EffectsCardiacRadiation therapyAnthracyclinesValvular diseasePericarditisMyocardial infarctionCongestive heart failurePulmonaryRadiation therapyBCNU/CCNUBleomycinRestrictive lung diseaseExercise intoleranceRenal/UrologicalRadiation therapyPlatinumsIfosfamide/CyclophosAtrophy or hypertrophyRenal insufficiency or failureEndocrineRadiation therapyAlkylating agentsGrowth failurePituitary, thyroid, adrenal diseaseOvarian or testicular failureDelayed 2o sex characteristicsInfertilityCNSRadiation therapyIntrathecal chemotherapyLearning disabilitiesCognitive dysfunctionPsychologicalCancerPost-traumatic stressEmployment & educational problemsInsurance discriminationAdaptation/problem solvingSecond malignanciesRadiation therapyAlkylating agentsEpipodophyllotoxinsSolid tumorsLeukemiaLymphoma
Factors contributing to late effectsAgingPremorbidconditionsGeneticBRCA, ATM, xerciseSunTumorFactorsLate EffectRiskHost diation therapyHudson MM. Cancer, 2005
Second Primary Cancer (SPC) 20% of incident cancers are a second (orsubsequent) primary cancer Causal pathways:–––––Lifestyle habitsAgingGenetic factorsTreatment exposures for the first cancerAll of the above (interactions)
SPC after Breast or Colorectal CancerRisk prediction model – 10-year cumulative risk of SPCCohort of 293,435 from 12 French registriesFEMALESCalendar period for first cancer – 2007-2010Age at firstcancer55 - 64 yrs65 - 74 75First Breast CancerFirst Colorectal Cancer10-yrDifference10-yrDifferencecumulative with general cumulative with generalriskpopulationriskpopulation6.8% 1.5%10.0% 3.0%9.3% 1.9%10.7% 2.2%10.5% 2.0%10.6% 1.6%Moitry M, et al. Cancer Epidemiol, 2017
SPC after Prostate or Colorectal CancerRisk prediction model – 10-year cumulative risk of SPCCohort of 293,435 from 12 French registriesMALESCalendar period for first cancer – 2007-2010Age at firstcancer55 - 64 yrs65 - 74 75First Prostate CancerFirst Colorectal Cancer10-yrDifference10-yrDifferencecumulative with general cumulative with generalriskpopulationriskpopulation13.1% 5.5%19.4% 6.3%16.0% 5.0%21.7% 3.1%16.4% 2.5%22.1% 4.4%Moitry M, et al. Cancer Epidemiol, 2017
SPC in TP53 carriersNCI Li-Fraumeni Syndrome Cohort (N 286)Risk of SPC by time since first cancer and by ageMai PL, et al. Cancer, 2016
SPC in Mismatch Repair (MMR) genesColon Cancer Family Registry (N 764)Cumulative risk of extracolonic cancer following CRCWin AK, et al. J Natl Cancer Inst, 2012
SPC following Hodgkin LymphomaDutch HL Cohort (N 3905)Age 15-50 at HL diagnosis, 1965-2000Schaapveld M, et al. N Engl J Med, 2015Van Eggermond AM, et al. Blood, 2014
Lung cancer after Hodgkin lymphomaCase-Control study from population-based registryAge at Hodgkin lymphoma – median 50 years60Relative Risk504030Non / Light SmokerModerate-Heavy Smoker20100N/NN/AlkRT/NTreatment GroupRT/AlkTravis LB, et al. J Natl Cancer Inst, 2002
VignetteMary presents to your office with a 2 month history ofvague, non-exertional chest pain. She was treated atthe age of 20 for stage IIA nodular sclerosing Hodgkinlymphoma with 21 Gy involved field radiotherapy,including the neck, mediastinum and the para-aorticnodes, and 6 cycles of ABVD.Mary’s only cardiovascular risk factor is dyslipidemia.She has also been fairly sedentary. Her paternal unclehad an MI at the age of 59 yrs.
VignetteMary presents to your office with a 2 month history ofvague, non-exertional chest pain. She was treated atthe age of 20 for stage IIA nodular sclerosing Hodgkinlymphoma with 21 Gy involved field radiotherapy, What is her ‘pre-probability’ risk of a myocardialincluding the neck, mediastinum and the para-aorticinfarctionthe next10 years?nodes, and in6 cyclesof ABVD. Whatisthepreferrednextstep,otherthanMary’s only cardiovascular risk factor is dyslipidemia.proceedingto a cardiaccatheterization?She has also beenfairly sedentary.Her paternal unclehad an MI at the age of 59 yrs.
21 Gy Irradiation to 20 year-old withHodgkin lymphomaCourtesy of Constine LS.
Hodgson DC, et al. Semin Radiat Oncol 2007
Involved Nodal RadiationCourtesy of Hodgson D.
Mantle / Mediastinal RadiotherapyMen and women treated with mediastinal radiotherapy have asubstantially elevated risk of coronary artery disease. 20 yrs post moderate-dose RT (37.2 Gy),actuarial risk of symptomatic CAD 21.2%Reinders JG, et al. Radiother Oncol, 1999 By 30 yrs, incidence of MI 12.9%Aleman BM, et al. Blood, 2007 Standardized Mortality Ratio with MI 3.2Swerdlow AJ, et al. JNCI, 2007
Cumulative incidence of coronary heart diseasein HL survivors diagnosed prior to age 51 (1965-1995)10-yr risk 12%By age 40, 5.5% with CHDvan Nimwegen FA, et al. J Clin Oncol, 2016
americanheart.org
ClinCalc.com
10-year risk 12%ClinCalc.com
Need for validatedCAD risk prediction models10-year risk 10-15%for cancer survivorsSalz T, et alMSK and Danish Cancer InstituteClinCalc.com
Risk-based health care of cancer survivors Monitor for recurrence of cancer Surveillance for second cancers and late effects Early diagnosis and intervention Prevention Tobacco use, physical activity, calcium intake Counseling and targeted educationOeffinger KC. Institute of Medicine, 2003Oeffinger KC, Hudson MM. CA Cancer J Clin 54:208-236, 2004
Cancer Survivors at DukeIn the interval from January 1, 2016 – June 30, 2017 (18 months),the following unique patients were seen by Duke oncology providersCancerINTERVAL FROM CANCER DIAGNOSIS, YRS 3.03.0 – tGYNAll cancers1050857450327845.0 – 9.9903429610.0 – 20.07722729Courtesy of Steve Power and Phillip Maxwell
Cancer Survivors at DukeIn the interval from January 1, 2016 – June 30, 2017 (18 months),the following unique patients were seen by Duke oncology providersINTERVAL FROM CANCER DIAGNOSIS, YRSWith 2018Value-BasedCare, 3.03.0 – 4.95.0 – 9.9 10.0 – 20.0can we (DCI/DUHS) affordBreast1050503903772to continue following 7,000 individualsGI1460 year cancer300408169who are 5 survivors?CancerGUGYNAll urtesy of Steve Power and Phillip Maxwell
Primary Care Physicians and SurvivorshipSystematic review of 35 articles, 10,941 PCPs 45% involved during cancer treatment 70-80% during survivorship 95% preferred a more active role across phases 50% felt unprepared to manage late effects Rarely and inconsistently received sufficientinformation from oncologistsLawrence RA, et al. J Gen Intern Med, 2015
Risk-stratified survivorship health careHigh risk Bone marrow transplantation High dose radiation orchemotherapyIntermediate risk Moderate dose radiation Moderate dose chemotherapyLow risk Surgery only, or Surgery with low dosechemotherapy
Oeffinger KC, McCabe MS. J Clin Oncol, 2005McCabe MS, et al. Semin Oncol, 2013
Oeffinger KC, McCabe MS. J Clin Oncol, 2005McCabe MS, et al. Semin Oncol, 2013
Moderate / Low Risk Cancer Survivors Independent Advanced Practice Provider (NP/PA) Time of transition Focus of visit––––Surveillance for recurrence of primary cancerPreparation of Survivorship Care PlanEvaluation for medical and psychosocial late effectsEducation about survivorship issues and availability ofcommunity resources– Health promotion counseling Duration of care by APP Shared care with primary care provider Pilot nurse navigator embedded in primary care
High Risk Cancer Survivors MD-APP team Populations:– Cancer survivors at high risk of a serious late effect orwith persistent multi-organ toxicity– Chronic cancer patients Focus of visit– Surveillance for recurrence of primary cancer– Screening and management of late effects– Other aspects of risk-based survivorship care Duration of care Shared care with primary care provider
ASCO Survivorship Care Plan ivorship-care-clinical-tools-and-resources
Duke Center for Onco-Primary CareAims of Center1. Deliver evidence-based, patient-centered,personalized health care across the cancercontinuum by enhancing the interface betweencancer specialists and primary care clinicians;2. Conduct innovative research with cutting-edgetechnology that can be translated to thecommunity setting; and3. Train and educate the next generation ofclinicians and researchers to extend this mission.
Duke Center for Onco-Primary CareWashington / Fulkerson / OwensKastan / PatiernoDukeCancerInstituteDuke Regional and Duke RaleighDuke Cancer Research Network(23 sites across eastern U.S.)WakeMedOnco-Primary Care TeamOeffingerCorbettRagsdaleAssociate Director2 physician researchers2 health service researchersSupport staffDukePrimaryCare
Duke Center for Onco-Primary CareExternal Advisory BoardPatricia Ganz,MD UCLA /Johnsson CancerCenterLos Angeles, CAAnn Partridge,MD Dana FarberCancer InstituteBoston, MARonald Kline, MDCenters forMedicare ServicesWashington DCEva Grunfeld, MD, DphilDept of Family MedicineUniversity of TorontoToronto, CanadaLarissa Nekhlyudov,MD Brigham &Women’sDana FarberBoston, MARichard Wender, MDAmerican CancerSocietyAtlanta, GADeborah Mayer, RN, PhDUNCLineberger Cancer CenterChapel Hill, NCJamie von Roen, MDAmerican Society ofClinical OncologyAlexandria, VAWendy DemarkWahnefried, PhD, RDUAB Cancer CenterBirmingham, ALElectra Paskett, PhDOhio State UniversityCancer CenterColumbus, OH
Duke Center for Onco-Primary CareDistributed Care ModelDuke Primary Care(224 primary care physiciansin 34 sites across 7 counties)DCIOnco-trainedprimary care physician
Target Populations – Catchment Area Patients throughout Duke University Health System(225 Primary care clinicians in 34 practice sites (rapidly expanding)– 7,500 new cancer cases per year Across the Eastern seaboard through the 21-center DukeCancer Network Via future DUHS partnerships and alliances including theexpansion into Wake County and statewide. Encompassed within these clinical and research goals willbe a concerted effort to reduce cancer disparities withinthese populations and, in partnership with otherinstitutions, throughout North Carolina.
Summary Currently, there are shortcomings in ourcare across the cancer continuum Care will become much more complex inthe next decade Need for radical practice redesign International examples:– Canada (Grunfeld)– Australia (Emery / Jeffords)
Questions?kevin.oeffinger@duke.edu
Duke Community & Family Medicine Grand Rounds June 18, 2018 Against the Grain Bringing PCPs “back” into Cancer Care through Onco-Primary Care Kevin C. Oeffinger, MD Director, Duke Center for Onco-Primary Care Professor with Tenure Department of Medicine Secondary: Depar
PCPs (PCPs) and Specialty Care Physicians (SCPs) can access these guidelines through CROSS (Franciscan St. Francis Health intranet) or by contacting Nancy George at 782-7698 or Nancy.George@franciscanalliance.org. SFHN asks that PCPs utilize the guidelines when referring to capitated and non-capitated specialists.
Ovarian cancer is the seventh most common cancer among women. There are three types of ovarian cancer: epithelial ovarian cancer, germ cell cancer, and stromal cell cancer. Equally rare, stromal cell cancer starts in the cells that produce female hormones and hold the ovarian tissues together. Familial breast-ovarian cancer
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Breast Cancer Breast cancer is one of the most common forms of cancer among women (40,290 in 2015). It is second only to lung cancer as a cause of cancer deaths in American women, One-third of women with breast cancer die from breast cancer, One out of every eight women will be
PERFORM SOME BALLET THEMES: Choose from the three themes on the Tchaikovsky Ballet Music sheet and perform on an instrument of your choice. Add in the left hand chords if you are playing on keyboard or piano. You could play either: Theme from the Dance of the Sugar Plum Fairies The Waltz from Sleeping Beauty The March from the .
