Sutter Health Cancer Services and Programs

S u t t e r H e a l t h C a n c e r S e r v i c e s a n d P r o g r a m sSutter HealthCancer Program FacilitiesMany dedicated individuals make this report, and theprograms and services described in it, possible. Theircontributions are gratefully acknowledged.ABSMC-Alta BatesMichael Cassidy, MD, Medical DirectorNorman Cohen, MD, Cancer Committee ChairJeffrey Wolf, MD, Medical Director, BMT ProgramPam Davis, RN, Director Oncology ServicesStephen Bishop, CTR, Manager, Cancer Data ServicesEric Gold, Oncology Analyst/ProgrammerCPMCKathleen Grant, MD, Medical DirectorJohn Holt, Director of OncologyJoyce Louie, RHIT, CTR, Oncology Data AnalystEMCRavi Arora, MD, Cancer Committee ChairBryan Daylor, Vice President, Ancillary andSupport ServicesMargaret Courtney-Wildman, Tumor RegistrarMGHLloyd Miyawaki, MD, MPH, Medical DirectorLinda Tavaszi, Executive Director of PhysicianRelationsLois Inferrera, CTR, Coordinator, CancerData/Registry ServicesMMCDavid Shiba, MD, Medical Director and CancerCommittee ChairBeverly Paderes, Cancer Services ManagerCheryl Casey, Cancer Registry and SpecialProjects CoordinatorAnnette Glass, CTR, Certified Tumor RegistrarMPHSBrian Henderson, MD, Cancer Committee ChairSheila Littrell, RN, Director of Cancer ProgramMichelle Alexander, CTR and Nancy Richards, CTR,Cancer Registry CoordinatorsABSMC - SummitLisa Bailey, MD, Medical DirectorLarry Strieff, MD, Medical DirectorPam Davis, RN, Director Oncology ServicesStephen Bishop, CTR, Cancer Data ServicesCoordinatorSMCSGregory Graves, MD, Medical DirectorAntoine Sayegh, MD, Medical Director, BMT ProgramMargaret Mette, Assistant AdministratorLindsey Holloway, Clinical Research ManagerCheryl Nightingale, CTR, Tumor RegistrarSRMCUma Gowda, MD, Medical DirectorDeborah Dix, RN, Oncology DirectorDiana Pope, CTR, Cancer Center SupervisorSSMCElizabeth Odumakinde, MD, Medical DirectorJanice Hoss, RN, BSN, OCN, Administrative DirectorData analyses contributed by Eric Gold, OncologyAnalyst/Programmer at Alta Bates Medical CenterThe Sutter Health Cancer Programs offer a complete array of services forcancer patients, including screening, diagnosis, treatment, education andsupport. These services include advanced treatments such as bone marrowtransplants, specialized treatments such as cryosurgery, and complementarymedicine approaches such as interactive guided imagery.Services are available in nine geographic locations throughout theSacramento/Sierra Region, the Central Valley and the San Francisco Bay Area.See page 3 for a complete listing of services offered at each organization.Sutter Health Cancer Programs are available at:Alta Bates Summit Medical Center– Alta Bates (ABSMC)2450 Ashby AvenueBerkeley, CA 94705510-204-2793California Pacific Medical Center(CPMC)2333 Buchanan StreetP.O. Box 7999San Francisco, CA 94115415-600-2080Eden Medical Center(EMC)20103 Lake Chabot RoadCastro Valley, CA 94546510-537-1234Marin General Hospital(MGH)250 Bon Air RoadP.O. Box 8010Greenbrae, CA 94912415-925-7000Memorial Medical Center (MMC)1700 Coffee RoadModesto, CA 95355209-526-4500Mills-Peninsula Health Services(MPHS)Dorothy E. Schneider Cancer Center100 South San Mateo Dr.San Mateo, CA 94401650-696-4509Alta Bates Summit MedicalCenter – Summit (SMC)350 Hawthorne AvenueOakland, CA 94609510-655-4000Sutter Medical Center,Sacramento (SMCS)2800 L StreetSacramento, CA 95816916-454-6500Sutter Roseville Medical Center(SRMC)One Medical PlazaRoseville, CA 95661916-781-1617Sutter Solano Medical Center(SSMC)100 Hospital DriveVallejo, CA 94589707-554-44442 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C l i n i c a l a n d P a t i e n t S u p p o r t S e r v i c e sIntroductionCancer Support ServicesThis table displays the broad range of services available from the Sutter Health ACoS Cancer Programs. For specificfacility locations and contact information, see page 2. Although this table is reflective of actual services physicallyat the locations, we understand that many of you offer these services through referrals within your region and otherSutter Affiliates.SERVICES ABSMC CPMC EMC MGH MMC MPHS SMCS SRMCACoS-Certified Cancer Center Y Y Y Y Y Y Y YBone Marrow Transplants Y YBrachytherapy Y Y Y Y Y Y YCancer Surgery Y Y Y Y Y Y Y YCancer Clinical Trials & Prevention Trials Y Y Y Y Y Y Y YCancer Educational Programs Y Y Y Y Y Y Y YCancer Support Groups Y Y Y Y Y Y Y YCommunity Screenings for Cancer Y Y Y Y Y Y YIndoor Pool for Patient/Rehab Y Y YCore Needle Biopsy - Ultrasound Y Y Y Y Y Y Y YCore Needle Biospy - Stereotactic Y Y Y Y Y Y YStereotactic Radiosurgery & Radiotherapy on Site Y Y Y Y YCryosurgery Y YGamma Knife on SiteYInfusion Therapy Y Y Y Y Y Y YInterventional Radiology Y Y Y Y Y Y Y YLiver Transplant for HepatomaYMammography Y Y Y Y Y Y YMinimally Invasive Surgery Y Y Y Y Y Y Y YPediatric Cancer Care and Surgery Y Y YPET – Positron Emission Tomography on Site Y Y Y Y Y YImage-Guided Prostate Radiation Therapy Y Y Y Y Y Y YRadiation Oncology Services Y Y Y Y Y Y Y YRadiofrequency Ablation on Site Y Y YIMRT Y Y Y Y Y Y Y YSPECT Y Y Y Y Y Y Y YTumor Board Y Y Y Y Y Y Y YTumor Registry (in-house) Y Y Y Y Y Y Y YOUTPATIENT SERVICESValet Parking Y Y Y Y Y YComprehensive Breast Center Y Y Y Y Y Y YCancer Treatment Center Y Y Y Y Y YChemotherapy Treatment Y Y Y Y Y Y Y YHome Care & Hospice Y Y Y Y Y Y Y YNutrition Services Y Y Y Y Y Y Y YPain Management Y Y Y Y Y Y Y YComplementary Medicine Program Y Y Y Y2005 Annual Cancer Center Report — 2004 Statistical Review | 3

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sABMCAlta Bates Medical CenterNorman Cohen, MDChair, Cancer CommitteeAlta Bates Medical Center (ABMC)provides comprehensive care for itsmore than 1,065 newly diagnosedcancer patients each year. A full rangeof inpatient and outpatient servicesfor all phases of malignant disease,from prevention and screening tocomprehensive medical, surgical andradiation therapy for all cancer sitesare offered at both the main hospitalcampus on Ashby Avenue and theoutpatient cancer center located at theHerrick campus in downtown Berkeley.In November 2004, ABMC was surveyedby the Commission on Cancer (COC)of the American College of Surgeons(ACoS) and awarded a full three-yearapproval with three commendations.The top five primary cancer diagnosesat ABMC in 2004 were breast, lung,prostate, colorectal and non-Hodgkin’slymphoma (NHL), which together total57 percent of all reported cases. Breastcancer is the most common cancerdiagnosis, comprising approximately 20percent of all cancer diagnoses and 36percent of the top five primary sites onthe body, including the breast, prostate,lung and colon. Of the total cancer casesat ABMC in 2004, prostate made up 11percent, lung 10 percent, colorectal 9percent and NHL 6 percent.Complete diagnostic and therapeutic servicesare offered for patients with breastcancer, including services for disabledwomen through Breast Health Accessfor Women with Disabilities (BHAWD).For a full description of BHAWD programsand services, visit their website athttp://www.bhawd.org/.The cancer education program for bothprofessionals and the community hasbeen enhanced by specialty conferences,regular tumor boards and didacticprograms. During the past year, it hasbeen expanded to include patient forumsat which topics of interest are presentedby experts in an informal atmospherethat encourages interactive participation.The Carol Ann Read Breast HealthCenter is expected to formally openin 2006. Architectural plans havebeen finalized and the site has beenapproved for the Providence Pavilionon the Summit Campus; however,some services will be offered under itsauspices prior to the official opening.Breast Health Center Manager MereditheMendelsohn, MPA, along with KathleenColloton, RN, have developed andimplemented the Compassionate PeerAdvocacy and Support Program, inwhich breast cancer survivors assist newpatients in adjusting to the complexitiesof their diagnosis and treatment.Clinical research is a strong componentof the overall ABMC Cancer Program.ABMC participates in National CancerInstitute-sponsored cooperative groupprograms through Sutter Western DivisionCancer Research. The program alsooffers pharmaceutical company studiesthat provide access to new biologic andpharmacological agents for approximately150 to 200 new patients each year.The Alta Bates Comprehensive CancerCenter (ABCCC) Radiation Oncologyunit, located on the Herrick Campusof Alta Bates Summit Medical Center(ABSMC), a Varian Center of Excellence,offers state-of-the-art therapeuticservices and will soon add stereotacticradiosurgery for both brain andextracranial sites.A major programmatic undertakingmandated by the COC is the merger ofcancer program activities for all threeABSMC campuses. It is expected thatthe consolidated cancer program will befully implemented and functioning earlyin 2006 with a combined annual casevolume of more than 2,100 new cases.For more information, please visit ourwebsite at http://www.altabatesummit.org/.4 | 2005 Annual Cancer Center Report — 2004 Statistical Review

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sCPMCCalifornia Pacific Medical CenterKathleen Grant, MDChief, Division of Hematology andMedical OncologyIn 2004, the California Pacific MedicalCenter (CPMC) Cancer Programcontinued its steady growth as thelargest single cancer program inthe Sutter system. There were 1,961accessioned cases, of which 1,698were analytic cases. The most frequentdiagnoses were breast cancer (370cases), colorectal (204), prostate (160),non-small cell lung cancer (131), livercancer (125) and pancreatic cancer (122).The 263 nonanalytic cases, frequentlyrepresenting more advanced cancerstransferred to CPMC for specializedmanagement, included cutaneousmelanoma; breast, lung and prostatecancers; leukemia and colon cancer.In 2004, the cancer program wasawarded a three-year certificationof approval in the teaching hospitalcancer program category by the ACoSCommission on Cancer, with multiplecommendations. The analysis of canceroutcomes, 100 percent compliance withAmerican Joint Committee on Cancer(AJCC) staging, continuing educationof the cancer registry staff, and clinicalresearch trial accrual were all singledout. The program also received highmarks for CPMC’s prevention and earlydetection programs.Highlights of the cancer programinclude educational materials for theSpanish-speaking community andtranslations of materials into Russianand Chinese, several continuingeducation programs including theMini-Medical School, complementaryand alternative services offered byCPMC’s Institute of Health and Healing(expanded to provide complementarymassages to oncology patients), and a12-week wellness program for womenwith cancer. The continuum of cancercare also includes a Palliative CareProgram with consultations availablefor inpatients and outpatients, anddedicated palliative care beds on two ofthe three campuses.The Department of Psychiatry hassponsored a Radiation Oncologysupport group that includespsychosocial services, nutritionconsults, massage therapy and guidedimagery, and pastoral services. CPMCalso participated in the Race for theCure, Great American Smoke Out,Light the Night Walk, AIDS Walk withAlice radio station, and the AmericanCancer Society’s Relay for Life.The Department of Radiation Oncologyhas begun construction of a third linearaccelerator vault to meet increasedpatient demand. Specialized radiationtreatment options continue to expand.It now offers high-dose-rate brachytherapytreatment for prostate andgynecologic cancers, as well as othersites. Partial breast radiation treatment(conformal and balloon — or Mammosite)is available for selected patientswith breast cancer. Neuro-oncology serviceshave also expanded with intraoperativebrain mapping via a specializedMRI connected to the brain lab, thustreating small tumors more accuratelyand limiting postoperative deficits inneurologically complex areas. Centralnervous system lesions can be treatedwith intensity-modulated stereotacticradiation treatment.CPMC now has regularly scheduledsubspecialty tumor boards forgastrointestinal cancers, head and neckcancers, genitourinary cancers, neurooncology,and gynecologic, breast andlung cancers. All of these tumor boards,in addition to the regular general cancertumor board, include surgeons, medicaloncologists, radiation oncologists,radiology and pathology.Breast Cancer is the most frequent diagnosis at CPMC.2005 Annual Cancer Center Report — 2004 Statistical Review | 5

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sEMCEden Medical CenterMichael R. Forrest, MDChair, Cancer CommitteeGoals set and achieved in 2004 at EdenMedical Center include discussionsof clinical trials at cancer conferences,increased staff and physician participationin neuro-oncology conferences, beginningimplementation of CAP reporttemplates and complete review of rectalcancer diagnosis and treatment.As part of the Sutter Breast Project,Eden’s Cancer Committee noted an improvedrate of needle biopsies for initialbreast cancer diagnosis, and breastsurgical conservation rates improved.The problem separating the rates ofsentinel node from full auxiliary dissectionfor DCIS was resolved. Results of astudy on colonoscopy rates for patientsdiagnosed with colon cancer werepresented. Dr. Gordon Tang, neurosurgeon,reviewed a five-year study onbrain malignancies. Brain cases haveincreased since the opening of SutterEast Bay Neuroscience Center, and theneed to serve a more ethnically diverseand non-local population was noted.Quality improvement actions includedreviewing the lymphedema avoidancepolicy with the nursing units. TheLymphedema Clinic will be trackingthe use of wrist bracelets for inpatientsand outpatients. Outreach to underservedethnic groups for education oncancer prevention and screening wasconsidered a priority. Names and addressesof such groups were compiledby Social Services and used to increasemailings for community educationseminars by 40 percent.A rotation of cancer conferencephysician moderators was institutedand has run extremely well. A newrepresentative from the AmericanCancer Society joined the cancercommittee.Physician education programs includedColorectal Cancer Screening andDiagnosis, PET in Oncology, IdentifyingWomen at High Risk for OvarianCancer, and Radiation Oncology 2004– Randomized Trials. Nurses receivedin-services on chemotherapy deliveryand some attended classes held bySutter Health and the Bay Area TumorInstitute.Community education programs includedthe Annual Breast Cancer Symposiumfocusing on prevention, earlydetection and diagnosis. For ProstateCancer Awareness month, an eveningseminar was held. Creating PositivePatient-Doctor Relationships withseveral primary care and specialtyphysicians was successful. Skin cancereducation was included at an eveningforum, and smoking cessation programsand support groups were heldregularly, along with the Look GoodFeel Better and I Can Cope programs.Cancer screening and early detectioninformation was distributed at eachof the following outreach events: ACSRelay for Life, Blue Shield Health Fair,Run to the Lake Health Expo, CastroValley Festival, Alameda County andSan Leandro Senior Resource Fairs, andthe Hayward Chamber of CommerceBusiness Expo. Hospital employeesparticipated in the Great AmericanSmoke Out, Breast Cancer Awarenessactivities and the Komen Foundationfund raiser.Support groups for cancer patientsand their caregivers continue tobe presented at East Bay CancerA patient is evaluated at Eden’s Lymphedema Clinic.Support Group (EBCSG) under thedirection of Kirsten Severson, Ph.D.,of the Eden medical staff. The groupssupported have included general,breast, metastatic, caregivers, children7 to 13 years and 13 to 18 years whohave a parent with cancer, and twobereavement groups. Donationsfrom Eden Medical Center and thecommunity support EBCSG.Cancer registry surpassed theaccuracy and follow-up rates set bythe Commission on Cancer, and theprocedure manual was revised andupdated. The American College ofSurgeons approved the registry’sreference date change to 1998.Run to the Lake & Health Expo Cholesterol Screening andFruit Stand.6 | 2005 Annual Cancer Center Report — 2004 Statistical Review

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sMGHMarin General HospitalLloyd Miyawaki, MD, MPHMedical Director, Marin Cancer InstituteChair, Cancer CommitteeThe Marin Cancer Institute (MCI) continuesto provide excellent patient andcommunity service through a comprehensiveintegrated program of multidisciplinarycare. Accomplishments in2004 are best highlighted in the contextof its flagship Breast and GenitourinaryOncology Programs.Breast Health ProgramIn 2004, Marin General Hospital(MGH) served more than 2,800 peoplethrough 62 community educationevents, four screening events andseven breast cancer support groups.The Breast Cancer Tumor Boardreviewed 220 cases, discussing everypatient at initial diagnosis and eachsignificant change in management. Tobetter serve patients, the breast healthnurse navigator role was expanded tointervene at the time of biopsy, priorto any diagnosis. A comprehensivepathway was developed to guide andprovide support to women during thisstressful period.The Marin Cancer Institute continuedits focus on quality improvement,producing a breast cancer educationalsymposium for primary care providersthat featured speakers from eachdiscipline. It was extremely wellreceived and will be adapted forthe general public. MCI studiedmammography screening rates forprimary care providers and providedfeedback to individual providersas well as intervention strategies tomaximize screening rates. These rateswill be continually tracked to assessthe efficacy of our interventions.The MCI developed consensusWith early diagnosis and treatment, cancer patients cancontinue to enjoy a full life.guidelines for breast MRI indicationsand worked with local insurers tofacilitate approval. A research study ofhealing through horses (called EquineFacilitated Therapy) was developed toevaluate its effect on recovering breastcancer patients.Genitourinary Oncology ProgramIn 2004, MGH organized a weeklymultidisciplinary Genitourinary (GU)Tumor Board, where the managementof each patient at initial diagnosisand through every aspect of care isdiscussed. Recommendations are basedon consensus guidelines establishedthrough systematic literature reviews.A nurse navigator guides patientsthrough diagnosis, treatment andrecovery. Patients and their familiesare offered a unique multidisciplinaryconference with a comprehensive medicalteam (urology, radiation oncology,medical oncology, pathology, radiology,primary care, nursing, social workand cancer survivor/patient advocate).This year 75 patients were served, andpatient surveys demonstrated outstandingpatient satisfaction. Patient volumegrew substantially, including increasedreferrals from outside the county. Sincethe initiation of the program in 2003,radical cystectomies increased from 0to 17 per year. Between 2003 and 2004,prostate cancer procedures (surgery andradiation therapy) increased 75 percent.Marin General Hospital providedcommunity outreach through prostatehealth educational lectures, whichaddressed more than 350 peoplethrough nine community groups. MGHalso organized two free prostate cancerscreening events, serving 443 men atfive sites over four days, specificallytargeting minority and underservedpopulations. One-hundred-and-thirtymen were advised to undergo furtherevaluation.MGH Goals for 2005• Prepare for successful ACoS survey;• Launch GI Oncology Program.Initiate a GI Tumor Board andproduce a primary care providereducational event;• Implement Palliative Care Programin association with Hospice of Marin;• Implement digital mammographywith computer-aided diagnosis;• Enhance Radiation OncologyDepartment with new CT simulator;• Expand options for breastconservation therapy with theintroduction of Mammosite partialbreasttherapy; and• Develop Cancer Recovery Program,including plans for first annualwomen’s retreat for cancer survivorsin 2006.2005 Annual Cancer Center Report — 2004 Statistical Review | 7

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sMMCMemorial Medical CenterDavid Shiba, MD, PhDMedical Director, Cancer ServicesChair, Cancer CommitteeMemorial Medical Center’s (MMC)ACoS-accredited Community HospitalComprehensive Cancer Programcontinues to provide state-of-the artcancer care for patients in Stanislausand surrounding counties.Quality Improvement ActivitiesIn 2004, MMC continued its work withSutter Health’s systemwide breastcancer project. A breast set-up in-servicewas presented to ensure that all treatingtherapists and simulation therapistsare using the same parameters whensetting up and treating breast tangents.Patient satisfaction and painmanagement continue to be a majorfocus of the program. An auditingprocess was instituted in radiationoncology to improve documentation,communication, error prevention,efficiency and patient outcomes.Nationally recognized speakersbrought the latest in cancer care toMMC’s professional community.The 21st Annual Cancer Symposiumfocused on palliative care, painmanagement and complementarytherapy, including both professionaland community presentations in musictherapy. Clinical research through ourECOG affiliation with Stanford and theCancer Trials Support Unit allows thecenter to offer the latest treatments topatients. MMC’s cancer registry had ananalytic case load of 851 in 2004 withan accuracy rate of 98.5 percent and afollow-up rate of less than 93 percent.Launching a formal Complementary Therapy Program, which includes a complementary therapy room, has been one ofMMC’s major accomplishments this year.New Program Services, TechnologyAnd EquipmentComplementary therapy began witha generous donation from the MMCFoundation and a new complementarytherapy treatment room. Additionalfunding from the foundation will allowthe program to expand. Music therapywas incorporated in the oncology unitand touch therapy in radiation oncology.MMC launched a new community-basedintroductory complementary therapyseries called The Healing Journey. InSeptember 2005, a new writing therapygroup began, and in October a newlymphedema support group started.Work has continued to establish a painand palliative care consultative servicescheduled to open in 2005–06. A newdual-energy linear accelerator and CTsimulator will be added in the nearfuture, and mobile CT-PET scanningcapabilities are planned for the growingarray of services.Community Collaboration and BenefitThe monthly television program“The Cancer Report” is in its thirdseason, focusing on cancer-relatedtopics, survivors and caregivers. Thisyear featured many topics filmedthroughout Northern California,spotlighting physicians and services atother Sutter Health affiliates. In 2005,“The Cancer Report” was awardeda prestigious Telly award and DVaward. Staff continues to be activelyinvolved with various cancer-relatedorganizations, including the AmericanCancer Society, Community Hospice,Make-A-Wish Foundation, Leukemiaand Lymphoma Society, and — forthe first time this year — the LanceArmstrong Foundation.MMC provides community educationalforums on colon, prostate andbreast cancers; a lung disease programwill be added in 2006. The center alsoparticipated in health fairs, prostatescreening and celebrating survivorshipwith events like Daffodil Delightand an Evening of Hope fashion showfeaturing breast cancer survivors. MMCcontinues to sponsor Bear Facts for thechildren of cancer patients and RecreationalOpportunities for Cancer Kids.8 | 2005 Annual Cancer Center Report — 2004 Statistical Review

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sMPHSMills-Peninsula Health ServicesRex Greene, MDMedical DirectorIn 2004, the Dorothy E. SchneiderCancer Center at Mills-PeninsulaHealth Services focused on programdevelopment and educational outreachto physicians. The center saw a modestreduction in new cancer cases, whichparalleled regional and national trendsshowing a declining incidence ofnew cancer cases. At the other end oflife, the palliative care program grewdramatically.The GU Cancer Program initiateda monthly multidisciplinary tumorboard. The weekly general tumorand breast tumor boards continuedand nearly 100 percent of cases werediscussed prospectively. A GI CancerProgram centered on colorectal canceris in the works, as well as optimizingcare of esophageal and pancreaticcancers. To this end, the center obtainedendoscopic ultrasound to assist withpre-operative staging of GI tumors.Breast cancer care continued to meetor exceeded Sutter guidelines, andthe hospital moved closer to openingits Women’s Center, which will housethe breast center and facilitate thedevelopment of a breast clinic.New and Expanded ProgramsThoracic oncology routinely presentednew lung cancer cases to the generaltumor board. Per national guidelines,PET scanning and mediastinscopywere performed in staging most newlydiagnosed cases. The breast centercontinued its high performance, andthe GU program discussed guidelinesfor treatment of moderate- to high-riskearly prostate cancer patients. Qualitybenchmarks were created for the fourmajor cancers.In its second full year, palliative care(PC) saw nearly 600 patients andreduced pain scores by five points onthe 0–10 pain scale. Patient satisfactionwith pain management continued toimprove hospitalwide, exceeding the60th percentile for most of the year.Cost savings from PC consultationexceeded $350,000. The center heldweekly multidisciplinary care conferencesand repeated its Palliative Careat the Bedside training for medicaland nursing staff. Staff presented theprogram to the National Hospice andPalliative Care Organization’s annualconference and a number of otherregional conferences and workshops.Betty Ferrell, RN, PhD, spent a dayconferring with the team and presenteda strategy on generating a hospitalwidecommitment to pain control.Research and EducationIn February, Mills-Peninsula launchedthe First Annual Dorothy E. SchneiderCancer Center Symposium on NewApproaches and Technologies in CancerCare and gave a symposium of cancerprevention for primary care physiciansin October. Lectures were given to themedical staff on pain management inresponse to AB 487 and SB 151. The I-ELCAP lung cancer screening study continued.Accruals now exceed 100 cases,and the first early stage lung cancerwas detected. The center participated incooperative group clinical trials and wasactive on the Sutter Science Committee.The pilot study of guided imagery inoutpatient surgery showed significantimprovement in pain control.LeadershipMills-Peninsula continued its active rolein Sutter Health initiatives in cancerand palliative care. Dr. Henry Greenechaired the Sutter West Bay Consortium,which supports affiliated institutionsthrough strategic initiatives to developnew programs, enhance the quality ofcare and generate increased accrual tocooperative group clinical trials.2005 Annual Cancer Center Report — 2004 Statistical Review | 9

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sSMCSummit Medical CenterLarry Strieff, MDMedical Director, Inpatient andOutpatient Infusion ClinicThe Carol Ann Read Breast Center isnearing the construction phase.Located at the Summit campus in theProvidence Pavilion, this facility willrepresent the first comprehensive breastcenter in the East Bay Area.Dr. Lisa Bailey has been named thedirector of the breast center. She has ledthe effort to establish a state-of-the-artfacility over the last six years. Dr. Baileyhas emphasized a bi-campus participationof physicians, stressing the needfor an advanced array of sophisticatedtechnology support. Meredithe Mendelsohn,MPA, has taken the role ofmanager of the Carol Ann Read BreastCenter after previously working in thatrole at the UCSF Breast Center.Occupancy is anticipated for early2007, and several of the breast centerprograms are already in place orunder development. These include theCompassionate Peer Advocacy andSupport Program (COMPASS) andHigh Risk programs.The COMPASS program is designedto match breast cancer survivors withrecently diagnosed patients to helpthem navigate through physician visits,testing and even treatment episodes.The potential for a genetic link betweenbreast cancer and other tumors willbe addressed by the High Risk Clinic.Patients and families will have theopportunity to evaluate their potentialfor elevated risks and potential riskreduction strategies.The Markstein Cancer Education andPrevention Center (MCEPC) continuesto stress community involvement.Through the Lawrence LivermoreLaboratory, the Department of Defensehas granted an additional three years offunding to continue research on the linkbetween diet and prostate cancer. Thecurrent study is focused on the relationshipbetween heterocyclic amines andthe subsequent development of prostatecancer in African-American men.The MCEPC support services includeMan to Man for men with prostatecancer, Look Good Feel Better andBy Your Side: Keeping Up With YourCancer Treatments.The radiation therapy department atSummit Medical Center continues togrow with new capabilities and options.The availability of 3D conformaltreatment, intensity modulated, imageguidedradiation therapy and respiratorygaiting all increase the efficacy oftreatment and reduce morbidity.The well-established Breast BrachytherapyProgram is now complementedby accelerated partial breast irradiation.These options have made therapiesavailable that are better tailored to themedical needs and personal choices ofselected breast cancer patients.10 | 2005 Annual Cancer Center Report — 2004 Statistical Review

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sSMCSSutter Medical Center, SacramentoGregory Graves, MDMedical DirectorSutter Medical Center, Sacramento(SMCS) incorporates a multitude ofprograms that provide comprehensivestate-of-the-art diagnostic and treatmentservices for patients with cancer. In 2004services were provided to more than1,700 newly diagnosed cancer patients.SMCS’s Bone Marrow TransplantProgram received its Foundation for theAccreditation of Cell Therapy certification.In addition, the Sutter CancerCenter received its three-year ACoSCommission on Cancer recertificationas a community hospital comprehensivecancer center.Advances in the Treatment ofLung CancerIn its ongoing drive to provideminimally invasive treatment options topatients with lung cancer, the center’sThermal Ablation Program, using bothRFA and microwave ablation with a CTguidedapproach, has seen more than250 patients since it began. In additionto lung cancer, the program also offersthis treatment for liver, renal, bone andadrenal tumors.The Heated Intraperitoneal Chemotherapy(Sugarbakers) Program continuesto expand, receiving referrals fromthroughout the western United States.In January 2005, a da Vinci® roboticssurgical program was initiated, enablingminimally invasive prostatectomiesto be performed, which decreasesblood loss and length of stay, andreduces incidences of incontinence andimpotence. The da Vinci® system willsoon be used in the treatment of othercancers.Kiumars R. Hekmat, MD, and Leonard E. Crawford Jr.,MD with the da Vinci robotBreast Cancer ServicesLisa Guirguis, MD, has joined the SMCSteam of surgical oncologists. Havingcompleted a fellowship in surgical oncologyat the National Cancer Institute(NCI) and the City of Hope Cancer Center,one of her areas of interest is developinga comprehensive Breast CancerCenter. SMCS also now offers partialbreast irradiation with MammoSite.Pediatric OncologySutter Children’s Services and theSutter Cancer Center is the fifth largestprogram in Northern California andninth largest in California. The PediatricOncology Program provides advanceddiagnosis, treatment and clinicalresearch services to pediatric cancer patients,with a bimonthly Pediatric BrainTumor Board.Support Service Enhancements:• Continue to promote smokingcessation with more classes. Thisyear’s success rate in sustainednonsmoking was 81 percent.• The Sutter Cancer Center now has anestablished Palliative Care Programto offer support and comfort aspatients transition from activetreatment toward end-of-life care.• The Breast Navigator Program hasmaterials that are now available inRussian, Spanish and Chinese.• Massage therapy was implementedin the Infusion Center and InpatientOncology Unit.• Complementary medicine programs,such as free social work counseling,free nutritional counseling, dancemovement therapy, art and musictherapy continue to be available.Goals for 2005–06• Develop comprehensive datadashboard to validate quality of care;• Expand Palliative Care Projectfrom the ICU into other areas of thehospital;• Recruit additional oncologyspecialists to meet the growingdemands of patients;• Investigate feasibility of a comprehensivebreast cancer center; and• Design and complete lobbyenhancement.2005 Annual Cancer Center Report — 2004 Statistical Review | 11

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sSRMCSutter Roseville Medical CenterAlan McNabb, MDCancer Liaison PhysicianCancer CommitteeThe Sutter Cancer Center, Rosevillecontinued a strong tradition ofproviding multidisciplinary diagnosis,treatment and management to the manyunique needs of cancer patients. TheCancer Center’s health care providerteam consists of physicians, physiciansubspecialists, nurses, technologists,data managers, social workers,researchers, research coordinatorsand many volunteers who strive toprovide state-of-the-art medical carewith a holistic approach. In 2004, SutterRoseville Medical Center (SRMC)underwent review and accreditationby the ACoS to continue it’s CancerCenter designation. SMRC passedit’s accreditation survey with theOutstanding Achievement Award, adesignation awarded to only 7% of allhospitals surveyed in 2004 and one ofonly two in Northern California.In 2004, 649 patients received treatmentfor their cancer at the Sutter CancerCenter, Roseville. The two mostprevalent cancers were breast (137) andprostate (125).The Breast Health Center continuesto grow and expand services. Inaddition to the Breast Health Nurse,who facilitates the patient’s treatmentplan from pre-surgery to long-termemotional and physical support duringtreatment, Sutter Roseville begandeveloping lymphedema and geneticeducation for patients.An enlarged cancerous prostate is shown on a tomographscan.The Breast Health Center currentlyprovides the following state-of-the-artservices all encompassed in one facility:stereotactic core biopsy, ultrasoundguidedcore biopsies, cyst aspirations,wire localizations, mammography andbreast ultrasound. Procedures are upby 7% in the Breast Health Center.The prostate seed program, whichstarted in 1999, continues to providean alternative for many men facingtreatment for prostate cancer. Fifty-fourpatients successfully underwent thistreatment option in 2005. A full scopeof prostate cancer therapies are offeredfor men not receiving brachytherapy astheir treatment regimen.SRMC’s cancer center added oneoncologist and one surgeon in 2004.The Sutter Cancer Center, RosevilleTumor Board uses a multifaceted approachto the treatment and care ofall cancer patients and meets weekly.Attendance is robust and includes notonly cancer specialists but many primarycare (medicine, family practice, OB)and subspecialty physicians as well.SRMC’s commitment to providingpatient’s patients with state-of-theart diagnosis and treatment is furthermanifested by the tumor registry, whichis actively following 5,442 cases fromthe Sutter Roseville facility.In 2004, 43 patients participated intreatment or prevention trials. Twentythreepatients were enrolled in theRadiation Therapy Oncology Groupstudies, 16 participated in chemotherapyor supportive care pharmaceutical-sponsoredtrials, three patients wereenrolled in National Surgical AdjuvantBreast and Bowel Project protocols, andone patient was enrolled in a cancerrelated nuclear medicine study. Thereare approximately 50 active therapeuticprotocols available to patients whoqualify.Goals for 2005 are to improve the timelinein treating breast cancer patientsand develop a rapid response processin the hospital for managing neutropenicsepsis. SRMC is expanding severalpatient support programs and, as always,working to provide state-of-theartmedical care in a compassionate andholistic setting for all Sutter Rosevillecancer patients.12 | 2005 Annual Cancer Center Report — 2004 Statistical Review

A n n u a l S u m m a r y o f P r o g r a m A c t i v i t i e sSSMCSutter Solano Medical CenterRussell NeilsonMarketing CoordinatorSutter Solano Medical Center’sadvanced, full service cancer centeropened in November, providingcomprehensive cancer care andimproved access and convenience to thecommunity, whose residents can nowreceive the care they need locally.The cancer center offers a wide rangeof current technology, treatments andsupport services, all in a compassionate,patient-centered environment. Servicesinclude medical oncology, radiationoncology, surgery, and supportive andcontinuing care services. Many soothingelements are incorporated into thedesign of the cancer center, includingmassage therapy, a serenity roomfor patients and families, a fireplace,waterways and gardens to enhance thehealing process.Ongoing professional educationincludes a series of “Ask the Professor”lectures by local and national speakersand bimonthly tumor boards.Chemotherapy certification is providedfor oncology nurses.In addition to the opening of the newcancer center, Sutter Solano is preparingfor the ACoS accreditation, which setsthe standard for excellence in cancercare. This accreditation will take placethe first quarter of 2006.Cancer Program RecognizedThe Overflowing Cup Breast Health andWomen’s Empowerment Program is acommunity effort to educate African-American women about breast cancerand early detection. This past spring,Sutter Solano was honored by thisorganization with its first PartnershipAward for supporting and sponsoringArchitect’s rendition of the newcancer center, which opened inNovember 2005November 2004 groundbreaking forthe new cancer center: Bob Glasgow,John Ray, Craig Mulfrod,Mel Jordan, Terry Glubka, CEO,Annette Taylor, Dale Welsh,Beth Whatley and Tony Intintolicancer projects that specifically benefitthe African-American community.Partnering With the CommunityCommunity education programs andfree health screenings were offeredthroughout the year: skin cancer screeningsduring Skin Cancer AwarenessMonth and a prostate cancer lectureand screenings during Prostate CancerAwareness Month. Sutter Solano alsoorganized a Women’s Health day eventthat featured clinical breast exams,blood pressure, cholesterol and bloodsugar screenings, and free or low-costmammograms.Sutter Solano continues to participatein community events, such as theAmerican Cancer Society’s Relay forLife, Look Good Feel Better program,lectures to service organizations andnumerous community health fairs.Other venues for public educationinclude articles in Your Health (Sutter’squarterly health and informationmagazine), health columns in thelocal newspapers, messages on localradio, and brochures and flyers sentto physician offices and communitygroups.Sutter Solano partnered with theSolano Coalition for Better Health tocommission the Solano County PublicHealth Department to produce a reporton the major health issues affecting thecounty’s residents. The findings of thisreport, Health Disparity in Solano County,2004, indicate that Solano County hasexceptionally poor health outcomes inseveral critical areas, particularly withAfrican-Americans. A local physicianhas agreed to assist Sutter Solano inworking with the coalition to addressthe identified health disparities.Sutter Solano recently created apartnership with the Wellness Communityof San Francisco East Bay toserve people with cancer, their familymembers and friends by offering cancersupport groups to the Solano Countycommunity.2005 Annual Cancer Center Report — 2004 Statistical Review | 13

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )FOCUSat Sutter HealthOverviewThe American Cancer Society estimates that in the United States there will be145,290 new cases of colorectal cancer diagnosed in 2005, and that 56,290 peoplewill die of the disease. Colorectal cancer remains the third most common cancerin both men and women, following lung cancer and either prostate or femalebreast cancer. It is still the third most common cause of cancer-related death foreach gender. However, when cancer deaths for both sexes are combined, the totalnumber of deaths due to colon and rectal cancer is larger than for either prostate orbreast cancer individually.Michael Cassidy, MDMedical DirectorAlta Bates Comprehensive Cancer CenterEric Gold, Oncology Analyst/ProgrammerAlta Bates Summit Medical CenterSee page two for abbreviations forSutter Health institutions.National incidence rates of colorectal cancer have declined since 1998, partly due toincreased screening and early polyp removal. 1 Mortality rates from colorectal cancerhave continued to decline in both men and women over the past 15 years, reflectingthe decreasing incidence rates since the mid-1980s and improvements in survival(Figure 1).1975 1980 1985 1990 1995 200080708070In 2004, among the nine cancer centers in the Sutter Health Network, colorectalcancer was the fourth most common malignancy overall (10.4%; behind breast,prostate and lung); more than 850 new cases were seen. With early diagnosis, thisdisease is highly curable. Due to the common nature of this malignancy and thepotential benefits derived from both early diagnosis and appropriate therapy,we have chosen colorectal cancer as the focus of the 2005 Sutter Health CancerPrograms Annual Report. This review can be considered a follow-up to the studypresented in the 2000 Sutter Health Cancer Programs Annual Report, whichreviewed colorectal cancer cases accessioned from 1989 through 1999.This analysis examines 7,877 new cases of invasive colorectal adenocarcinomadiagnosed and/or receiving first course of treatment at the nine Sutter Healthinstitutions from 1995–2004. For the purposes of this study, colon cancers weredefined as those malignancies arising from the following sites: cecum, ascendingcolon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoidand rectosigmoid. Rectal cancer was limited to cancers found in the rectum.Figure 2 (page 20) shows the volume distribution of colon and rectum cases amongthe Sutter Health hospitals, generally mirroring the size of the underlying oncologypopulation at each of these institutions.During the 10-year span of this study, 6,282 colon cancers and 1,595 rectal cancerswere noted, representing 80% and 20%, respectively, of the total colorectal cancercases. During this time period, the nine ACoS-accredited Sutter Health hospitalsshowed similar relative incidence of colorectal cancer — approximately 10% of allanalytic cases (with colon accounting for 8% and rectal accounting for 2% of analyticcases).Rate pe r 100,000605040302010Male IncidenceFemale IncidenceMale MortalityFemale Mortality001975 1980 1985 1990 1995 2000Year o f Diagnosis/De athFigure 1Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportU.S. Colorectal Cancer Incidenceand Mortality by Gender1975–2002 (SEER data, NCI, 2005)1Ries LAG, Eisner MP, Kosary CL, Hankey BF, MillerBA, Clegg L, Mariotto A, Feuer EJ, Edwards BK (eds).SEER Cancer Statistics Review, 1975–2002, NationalCancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975–2002/, based on November 2004 SEERdata submission, posted to the SEER website 200560504030201014 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )Age at DiagnosisThe overall median age at diagnosis was 73 years for colon cancer and 69 years forrectal cancer. For colon cancer the median age ranged from 72 (ABMC), (SRMC) and(MMC)) to 75 (EMC), (MGH), (MPHS), (SMCS), while rectal cancer ranged from 66(SMCS and MMC) to 73 (EMC). Overall, women were diagnosed at a slightly olderage than males for both colon (75 vs. 72) and rectal cancer (71 vs. 67), a trend that ismirrored in national data (colon – females 75 vs. males 71; rectum – females 70 vs.males 67). Figure 3 (page 20) reflects this trend, showing that for both colon andrectal cancer, compared to males, females show relatively fewer diagnoses in the50–69 age range and relatively more diagnoses in the 80+ age range. For both colonand rectal cancer and both genders, patients were most commonly diagnosed in the70–79 age range. An analysis of age distribution among Sutter Health institutionsrevealed markedly similar and consistent patterns.Just over 90% of both males and females with colorectal cancer were diagnosedafter age 50. These data are consistent with national data and screeningrecommendations, which indicate routine screening should begin at age 50 oryounger, if individual risk factors apply.Gender RatioThe overall distribution of colorectal cancer cases by gender show similar proportionsfor females (51%) and males (49%). Looking just at colon cancer, females withcolon cancer slightly outnumbered males at almost all hospitals (53% female vs.47% male, overall; Figure 4, page 21). A trend in the opposite direction was seenfor rectal cancer, where females were slightly outnumbered by males at almost allhospitals (46% female vs. 54% male, overall). This same trend was seen in our 2000colorectal study.Race/EthnicityColon and rectal cancer showed nearly identical patterns of race distribution(Figure 5, page 21), with differences among institutions probably reflecting thedemographics of the patient populations served. Overall, 74% of Sutter Healthcolorectal cancer patients were Caucasian. SMCS had the lowest percentage ofCaucasians (43–45%) due to large African-American and Asian components. ABMCand CPMC also had relatively lower percentages of Caucasians, reflecting largeAfrican-American (ABMC) and Asian (CPMC) populations.2005 Annual Cancer Center Report — 2004 Statistical Review | 15

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )FOCUSat Sutter HealthSite of DiseaseAs Figure 6 (page 22) shows, the distribution of colorectal cancers by site of disease(moving from right colon to left colon), was fairly similar across Sutter Healthinstitutions. Overall, rectum and sigmoid colon cancers were most common (20%)— but only slightly more so than carcinoma of the cecum (17%). When combiningsigmoid and rectosigmoid cases of colorectal cancer, approximately one-third of allcases could be found within the reach of the sigmoidoscope. When one adds thecases of rectal cancer and descending colon cancer, more than 50% of cases couldbe discovered this way. However, quite obviously, cancers of the cecum (14–24%of cases), ascending colon (9–14% of cases), transverse colon (6–9%) and hepaticflexure tumors (3–6%) are clearly missed by this technique.Figure 7 (page 22) illustrates changes with age in the specific site of colorectalcancer. Right side cancers (cecum, ascending colon, hepatic flexure and transverse)tend to increase with age, while left side disease (sigmoid colon, rectosigmoid andrectum) decrease with age. Thus, with increasing age there is a greater proportion ofcolorectal cancers in the part of the colon not accessible by the sigmoidoscope. Thissuggests the need for colonoscopy as a screening tool with advancing age in orderto diagnose these tumors at an earlier stage.TNM Stage at DiagnosisAn examination of stage at diagnosis reveals little variability among the nineSutter health institutions (Figure 8, page 23). Overall, invasive colon cancers werediagnosed more commonly at stage II (31%, range 26–34%), while most invasiverectal tumors were diagnosed at stage I (33%, range 22–40%). Unfortunately, 17%of Sutter colon cancer patients and 11% of rectal cancer patients presented withadvanced metastatic disease.Interestingly, despite the increased emphasis in recent years on the importanceof colorectal cancer screening, our analysis of Sutter Health data for three nonoverlappingtime periods (1989–94 vs. 1995–99 vs. 2000–04) unfortunately did notreveal any striking trend towards earlier diagnosis (Figure 9, Colon, and Figure 10,Rectum, upper graphs, page 24). While U.S. Surveillance Epidemiology and EndResults (SEER) data for similar time frames (Figures 9 and 10, lower graphs) appearto show stepwise increases in the proportion of stage I cancers diagnosed over thethree time periods, this trend is only apparent in Sutter Health rectal cancer patients.However, it should be noted that Sutter compares favorably to national dataat each time period for both stage I and stage IV colon and rectal cancers.While efforts at educating the public and physicians particularly have acceleratedduring the last few years and benefits might not yet be reflected, it may be worthwhilefor individual hospital communities to examine their own data and methodsof promotion of screening. This is of critical importance because earlier stage diseasenot only conveys a better prognosis but also requires less invasive therapy.16 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )Treatment ModalitiesTreatment modalities utilized in the treatment of colorectal cancer were generallysimilar across the Sutter Health institutions (Figure 11, page 25) 2 . Approximatelytwo-thirds of colon cancer patients were treated with surgery alone and one-quarterreceived combined therapy, including chemotherapy and/or radiation therapy inaddition to surgery. For rectal cancer, just over 40% of the patients were treatedwith some type of combination therapy and a similar percentage received surgicaltreatment only.Figures 12 (page 25) and 13 (page 26) show changes in treatment modality by stageof disease over time for colon and rectal cancer, respectively. The two figures overall,demonstrate the greater utilization of combination therapies in the treatment ofrectal cancer compared with colon cancer. Both cancers are increasingly treated withcombination therapies as the stage of disease advances. In addition, stage II andIII colon cancer cases diagnosed in the 1995–99 and 2000–04 time periods show adefinite increase in the use of combination therapies relative to 1989–94 cases. Thesame pattern is evident for all stages of rectal cancer.The relatively greater use of combination therapies in the treatment of rectal cancerin patients with stage II and III disease reflects the fact that recent studies havedemonstrated improved prognosis for patients treated with these modalities. Itshould also be noted that while it is not uncommon for stage IV colorectal cancerpatients to appropriately receive no cancer-directed therapy toward metastaticdisease (due to their advanced stage and/or the presence of co-morbid medicalconditions), this modality shows a decline at Sutter Health over the last 16 years(18–12% for colon cancer and 20–10% for rectal cancer).A cryostat machine is used to perform a cancer histologycross-section.It is interesting to note that just over 50% of colon cancer patients with stage IIIdisease diagnosed in recent years were treated with adjuvant chemotherapy.Figure 14 (page 26) demonstrates the importance of age at diagnosis in determiningtreatment modality in this group of patients. In recent years, more than 70% ofstage III colon cancer patients age 70 or below received adjuvant chemotherapy,compared with less than 40% of patients over age 70 at diagnosis. This may berelated to the general condition of the patient or possibly to physician/patient bias.A new benchmark of quality established by the ACoS recommends that we trackthe percentage of patients age 70 or less who have stage III disease receivingadjuvant chemotherapy. Individual hospitals and the Sutter Oncology Programwill therefore review our data to be sure we surpass this goal to ensure thatsurgery alone is appropriate with respect to patients’ stage at diagnosis, age andother co-morbidities that must be taken into account. A review conducted severalyears ago by the Sutter hospitals accredited by the ACoS of the appropriateness ofreferral to medical oncologists of patients who should be considered for adjuvantchemotherapy did not demonstrate any deficiencies in this expectation. Studies areongoing and controversies exist as to the best management of patients with stage IIdisease. This issue has not been substantially clarified since our 2000 report.2Analysis of treatment modality data was restrictedto Class 1 cases only. These are cases that were bothdiagnosed and received definitive treatment at thereporting facility.2005 Annual Cancer Center Report — 2004 Statistical Review | 17

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )FOCUSat Sutter HealthFive-Year Relative SurvivalIn order to directly compare survival rates for Sutter Health colorectal cancerpatients with the most recently available national data, 3 we calculated relativesurvival 4 for patients diagnosed in the 1995–2002 time period (Figure 15, page 27).Overall we find that five-year relative survival rates for both colon (64%) and rectal(67%) are comparable to those reported for the SEER U.S. population (63% and64%, respectively). Also, the Sutter Health data continue to reflect a trend for lowersurvival in African-Americans compared with Caucasians, which has been observednationally for many years.Alta Bates Comprehensive Cancer Center, a program ofAlta Bates Summit Medical CenterThe variability seen in survival values in Figure 15 is likely due to a combinationof factors, including stage mix, racial mix and small sample size. Figure 16 (page27) shows the important role that stage at diagnosis plays in determining fiveyearsurvival for colorectal cancer. In particular, patients with stage IV diseasehave dramatically reduced survival (7% and 12 % for colon and rectal cancers,respectively). Compared to other racial groups, African-Americans in the SutterHealth colorectal cancer population have the highest proportion of stage IV diseaseand the lowest proportion of stage I disease. These data are consistent with nationaltrends and may explain why hospitals with large African-American components(e.g., ABMC and SMC) show slightly reduced overall survival. Also of note,SRMC’s relatively low rectal cancer survival likely results from it having the highestproportion of stage IV patients (17%) among the Sutter institutions, combined witha small sample size.3SEER Public Use CD-ROM, 20054Relative survival data must be interpreted with caution.The relative survival rate facilitates comparison ofsurvival data from different groups of patients by takinginto consideration the likelihood that patients in a givenage group will die from causes unrelated to their cancer.Relative survival adjusts the actual observed survivalrates of a given patient population for the population’sage and gender structure relative to a “standard” U.S.population. This adjustment doesn’t take into accountfactors such as race and socioeconomic status, whichare known to affect survival rates for persons withcolorectal cancer. Also, the U.S. five-year relative survivalvalue used in this report for comparison purposes isbased upon SEER data obtained from population-basedcancer registries covering only about 10% of the U.S.population. To the extent that the patients seen at SutterHealth facilities during the 1995–2002 period differ fromthe U.S. subpopulation utilized for the SEER statistics,comparisons must be made with caution. Finally,comparisons among Sutter Health facilities with respectto survival rates must take into account the demographicvariability seen across Sutter Health institutions.ConclusionThis report reviews Sutter Health colorectal cancer data for the 10–year time period1995–2004. Where appropriate we have used 1989–94 data from our 2000 colorectalreport to give a 16–year time dimension to this study (1989–2004). Remarkably, littlehas changed during this 16–year period.Early diagnosis results in improved survival. It also allows for the option of lessinvasive surgery, particularly for rectal cancer, and can eliminate the need foradjuvant chemotherapy for either condition. Earlier diagnosis of rectal cancerobviates the need for radiation therapy, which has become a standard for stage IIand III rectal cancer.Our mission should be clear. Locally and nationally, our efforts to screen patients forcolorectal cancer must improve. A variety of techniques is considered acceptable.We must establish a concerted effort with our patients and primary care physiciansand facilitate the process to ease the ever-increasing burden on our primary carephysicians, improve our efforts in public education and ensure ready access toscreening for our patients.18 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )With regards to the treatment of patients diagnosed with colon cancer, ACoS willbe adopting several benchmarks as quality indicators to help us evaluate the careprovided at our institution, including:• Complete colonoscopy should be performed prior to the definitive surgicalprocedure for all patients except where contraindicated, such as patientspresenting with obstruction or perforation.• At least 12 lymph nodes should be included in the surgical specimen for coloncancer resections. (Note: The mean number of nodes examined increasedsignificantly over the time periods reviewed in this study: 1995–99, mean = 8.8nodes vs. 2000–04, mean = 12.0 nodes examined.)• Adjuvant chemotherapy should be administered to patients with node-positivecolon cancer.Specific benchmarks will be established and, with the assistance of our tumorregistries, the Sutter Health network should adopt these and other standards tocontinue to assist us in monitoring and improving the care of our colorectal cancerpatients.2005 Annual Cancer Center Report — 2004 Statistical Review | 19

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )FOCUSat Sutter HealthFigure 2Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportNumber of Analytic cases Figure 3Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportAge Distribution by Gender 20 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )Figure 4Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportGender Ratio Figure 5Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportRace/Ethnicity 2005 Annual Cancer Center Report — 2004 Statistical Review | 21

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )FOCUSat Sutter HealthFigure 6Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportColorectal Site Distribution Figure 7Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportSite of Disease by Age Group 22 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )Figure 8Focus on Colorectal Cancer: 1995–2004Sutter Health 2005 Cancer Programs Annual ReportTNM Stage at Diagnosis 2005 Annual Cancer Center Report — 2004 Statistical Review | 23

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )FOCUSat Sutter HealthFigure 9Focus on Colorectal Cancer: 1995–2004, Sutter Health 2005 Cancer Programs Annual ReportSutter Health (1989–2004) vs. U.S. SEER (1989–2002)TNM Stage at Diagnosis by Time Period Colon Cancer Figure 10Focus on Colorectal Cancer: 1995–2004, Sutter Health 2005 Cancer Programs Annual ReportSutter Health (1989–2004) vs. U.S. SEER (1989–2002)TNM Stage at Diagnosis by Time Period Rectal Cancer 24 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )Figure 11Focus on Colorectal Cancer: 1995–2004, Sutter Health 2005 Cancer Programs Annual ReportTreatment ModAlity Figure 12Focus on Colorectal Cancer: 1995–2004, Sutter Health 2005 Cancer Programs Annual ReportSutter Health (1989–1994 vs. 1995–1999 vs. 2000–2004)Treatment Modality by Stage of Disease by Time Period Colon Cancer 2005 Annual Cancer Center Report — 2004 Statistical Review | 25

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )FOCUSat Sutter HealthFigure 13Focus on Colorectal Cancer: 1995–2004, Sutter Health 2005 Cancer Programs Annual ReportSutter Health (1989–1994 vs. 1995–1999 vs. 2000–2004) Treatment Modality by Stage of Disease by Time Period Rectal Cancer Figure 14Focus on Colorectal Cancer: 1995–2004,Sutter Health 2005 Cancer Programs Annual ReportSutter Health(1989–1994 vs. 1995–1999 vs. 2000–2004)Treatment Modality by Age Groupby Time PeriodStage III Colon Cancer 26 | 2005 Annual Cancer Center Report — 2004 Statistical Review

C o l o r e c t a l C a n c e r ( 1 9 9 5 - 2 0 0 4 )Figure 15Focus on Colorectal Cancer: 1995–2004, Sutter Health 2005 Cancer Programs Annual ReportSutter Hospitals vs. U.S. SEER: 1995–2002Colorectal Five-Year Relative Survival Figure 16Focus on Colorectal Cancer: 1995–2004, Sutter Health 2005 Cancer Programs Annual ReportSutter Health Colorectal Cancer, 1995–2002Five-Year Relative Survival by Stage at Diagnosis 2005 Annual Cancer Center Report — 2004 Statistical Review | 27

B l o o d a n d M a r r o w Tr a n s p l a n t a t i o n P r o g r a m sProgramsat Sutter HealthAntoine Sayegh, MD, Medical DirectorBlood and MarrowTransplantation ProgramSutter Medical Center, SacramentoJeffrey Wolf, MD, Medical DirectorBlood and Marrow TransplantationProgram, Alta Bates SummitMedical CenterOver the past 21 years, the Blood and Marrow Transplantation (BMT) programswithin the Sutter Health network have provided successful advanced therapy for avariety of malignant and nonmalignant diseases. The programs at Alta Bates SummitMedical Center (ABSMC) and Sutter Medical Center, Sacramento (SMCS) haveperformed almost 800 transplantations, with results comparable to those seen atthe major cancer centers across the country and around the world. BMT offers hopeto many cancer patients who would otherwise face a very poor prognosis. Recentadvances in the field have made BMT an effective, life-saving treatment option and,in some cases, a first-line treatment choice.In 1984, Alta Bates established the first BMT program in Northern California. In1993, the BMT program at SMCS joined an already established solid organ transplantprogram at that facility. A single physician has directed each program sinceinception: Dr. Jeffrey Wolf at ABSMC and Dr. Antoine Sayegh at SMCS.In the late 1980s, the Alta Bates Cryopreservation Laboratory was established tosupport the BMT program, which had grown dramatically. As a fully accreditedindependent laboratory, it provides services to Children’s Hospital Oakland andits sister program at SMCS, as well as to the patients at Alta Bates. It also supportsthe nation’s only Sibling Cord Blood Program, receiving cord blood specimensfrom throughout the country, freezing them, and then providing them to transplantprograms around the world at the time of the transplant.In 1996, SMCS opened a completely new, family-focused, dedicated six-bed inpatientBMT unit. This unit, which is fully HEPA filtered throughout and has full criticalcare/telemetry capabilities, allows the SMCS BMT program to deliver the highestquality care to their patients throughout Northern California and the Central Valley.In 2003, the ABSMC BMT program became only the second BMT center in northernCalifornia to become fully accredited by the Foundation for the Accreditation of CellularTherapy (FACT). The program at SMCS received full FACT accreditationin 2005.28 | 2005 Annual Cancer Center Report — 2004 Statistical Review

B l o o d a n d M a r r o w Tr a n s p l a n t a t i o n P r o g r a m sBoth programs provide:• A multi-disciplinary team of health professionals tocoordinate patient care;• Specially trained, dedicated BMT nursing staff andcoordinators focused on continuum of quality care;• State-of-the-art facilities, including HEPA-filtered rooms tominimize the chance of infections;• A variety of counseling, educational and other supportservices, including comfortable, local lodging for out-of-town patients andfamilies;• Access to the latest collaborative national protocols through the SouthwestOncology Group; and• Efforts to advance the efficacy of BMT through the submission of data to theinternational BMT registry, the Combined International Bone Marrow TransplantRegistry.Kathy Albee, RN, BMT Coordinator, and Tony Saygeh,MD, BMT Medical Director.Clinical integration of the two programs includes coordinated efforts in a varietyof areas, including nursing education, protocol development, quality improvementand data management.How BMT WorksDepending on the disease being treated and the state of the disease in the patient,BMT functions in the following ways:• Corrects a deficient marrow state (or aplastic anemia);• Allows the patient to receive very high doses of chemotherapy and/or radiationtherapy (autologous); and• Provides the patient with a new immune system to replace a deficient one or tofight malignant disease (allogeneic).While the indications for BMT are always in evolution, BMT is primarily used insituations where conventional chemotherapy offers the patient little chance of cure.The following list is by no means comprehensive but details some of the diseasestreated:• Autologous BMT is indicated for recurrent lymphomas (such as Hodgkin’sand non-Hodgkin’s lymphomas), acute myeloid leukemia, multiple myeloma,recurrent testis cancer and rare other solid tumors (e.g., pediatric brain tumors).• Allogeneic BMT is used for all types of leukemia, inborn defects in immunecompetence and metabolism (sickle cell disease, for example), multiple myeloma,certain types of slow growing lymphomas, and conditions associated with bonemarrow failure, such as aplastic anemia, myelodysplasia and myelofibrosis.BMT involves the collection of hematopoietic stem cells (HSC) from the bonemarrow or the peripheral blood. Through a process called mobilization, bonemarrow stem cells can be moved into the bloodstream, thereby facilitating theircollection. The mobilization process is carried out by the injection of hematopoieticgrowth factors such as G-CSF. Recently, cord blood was found to be rich enough inHSC to support use in BMT procedures (predominantly in children).2005 Annual Cancer Center Report — 2004 Statistical Review | 29

B l o o d a n d M a r r o w Tr a n s p l a n t a t i o n P r o g r a m sProgramsat Sutter HealthTreatment OptionsThe two types of BMT (autologous and allogeneic) differ with respect to theorigin of the cells infused into the patient following the BMT treatment regimen.Autologous BMT involves re-infusion of the patient’s own stem cells collected priorto start of the treatment regimen. While it is more available and carries very lowmortality, it is not indicated for all diseases. Allogeneic BMT requires the collectionof stem cells from a matched donor and is primarily used in situations where thepatient’s own hematopoietic system is diseased. Therefore, it is less available andunfortunately more toxic, with a higher risk of death because of immune differencesbetween the patient and recipient, which cause Graft-vs.-Host disease. Donors canbe either family members or unrelated donors. At present the Sutter programsperform only matched-sibling donor transplants.Recent advances in BMT have widened the spectrum of diseases treated with BMT.Until the late 1990s, very high doses of chemotherapy were used in allogeneic BMTto “ablate” (destroy) the marrow of the patient. Recent studies have shown that“non-myeloablative” doses of chemotherapy are enough to allow the stem cells ofthe donor to settle and grow (“engraft”) in the patient. With time, these stem cellstake over and produce all the blood cells for the patient. They can also see the canceras a foreign antigen and thereby fight it, a phenomenon known as “graft-vs.-tumor”effect.Non-myeloablative or “reduced intensity” BMT is less toxic than traditionalallogeneic BMT, thereby allowing older patients to benefit from the procedure.It is also very useful in patients where the main purpose of the procedure is toinduce a graft-vs.-tumor effect, such as in low-grade lymphomas, indolent bloodmalignancies and most recently some solid tumors such as kidney cancer. Theseadvances have resulted in long-term disease-free survival for a number of heretoforeincurable diseases.30 | 2005 Annual Cancer Center Report — 2004 Statistical Review

O v e r v i e w o f C a n c e r R e g i s t r i e sRegistriesSutter Cancer ProgramStephen BishopCancer Data Services CoordinatorAlta Bates Summit Medical CenterCancer Registry Data CollectionAnd AnalysisThe cancer registries of the SutterCancer Program provide datamanagement services to comply withmandatory state cancer reportingregulations, as well as the data needsof clinicians, administrators andother qualified users across the Sutternetwork. In addition, Sutter CancerRegistries provide data to nationallevelcancer surveillance organizationsfor incidence measurement andepidemiological studies. The SutterCancer Registries contain data for182,659 cases; 9,589 new cases wereentered in the 2004 calendar year.The local registry databases containdemographic and clinical informationfrom diagnosis through treatment, aswell as annual lifetime follow-up data.The follow-up process, in addition toproviding critical information aboutdisease status and treatment outcomes,also performs a valuable service forphysicians and patients by remindingthem that regular reassessment of thedisease is vital for early detection ofrecurrences or subsequent primaries.As of the end of 2004, the Sutter CancerRegistries are actively following 61,581living patients.Data collected by each hospital areshared and aggregated for reports, studiesand cancer statistics for the SutterCancer Program as a whole. The abilityto look at our combined Sutter Healthdata provides a unique opportunity toRadiation therapists monitor the Radiation Oncology room at Alta Bates Comprehensive Cancer Center.evaluate care across our network. Atpresent, systemwide studies and qualityassurance projects are accomplishedthrough data exports and manualaggregation, and statistical analysis ofthe data. Through comparison with regionaland national statistics, the combineddata enables Sutter clinicians tomore effectively monitor trends in theincidence, staging, treatment, outcomeand survival of cancer patients treatedwithin our network.In addition to their routine cancerregistry responsibilities, Sutter cancerregistrars are often asked or volunteerto coordinate or participate in othercancer program activities outside ofthe cancer registry. At any of the nineACoS-accredited facilities in the SutterCancer Program, the cancer registrarmay coordinate or supervise cancerscreening programs, cancer supportservices, continuing medical educationfor oncology, cancer research, orvolunteers and auxiliary staff members.Sutter cancer registrars are oftenmembers of other standing medicalstaff or hospital committees, especiallyquality improvement committees.Cancer registrars often participate inor coordinate American Cancer Societyactivities, community health fairsand public education activities suchas Breast Cancer Awareness Monthevents in October and Prostate CancerAwareness Month events in November.2005 Annual Cancer Center Report — 2004 Statistical Review | 31

O v e r v i e w o f C a n c e r R e g i s t r i e sRegistriesSutter Cancer ProgramEach Sutter Cancer Program facilityis accredited by the ACoS and isregularly re-surveyed to ensurecontinuous compliance with itsaccreditation standards. In most cases,Sutter cancer registrars serve as theACoS certification coordinators attheir facilities, devoting many hoursoutside of their data managementresponsibilities to ensure that theircancer programs meet or exceed allACoS Cancer Program standards fortheir respective categories of approval.Table 1 below briefly summarizes thevolume of activity of each registry forcalendar year 2004.Table 12004 Sutter Health Analytic Cancer CasesSutter Cancer Registry StatisticsABMC CPMC EMC MGH MMC MPHS SMC SMCS SRMCReference Date 01/01/85 01/01/93 01/01/98 01/01/83 01/01/78 01/01/95 01/01/85 01/01/92 01/01/90Total Cases in Database 22,557 35,180 9,510 23,997 21,391 23,348 17,655 17,744 11,277Total Cases in 2004 1,072 1,960 387 682 851 961 1,008 1,767 901Total Active Follow-Up 9,129 14,996 1,184 6,320 5,468 6,922 6,401 7,834 3,327Follow-up Success % 91% 92% 97% 92% 93% 84% 89% 91% 85%Tumor Board Case Presentations 314 250 103 384 160 288 81 439 201■ General Tumor Board 127 96 93 130 102 79 33 117 143■ Breast Tumor Board 187 51 5 199 42 185 48 16 58■ Other Special Tumor Boards 0 103 5 55 16 24 0 306 0Total Data Requests 28 44 36 45 16 8 28 32 6032 | 2005 Annual Cancer Center Report — 2004 Statistical Review

S t a t i s t i c a l O v e r v i e wOverviewSutter Health 2004 Cancer Registry DataThis overview presents an analysis of 8,139 new cases of cancer 1 diagnosed and/ortreated at the nine ACoS-accredited Sutter Health institutions during 2004. Thisrepresents a very small (2%) increase in systemwide volume over last year’s totals. 2PATIENT VOLUME BY CLASSOF CASE (Figure 1)Figure 1 shows the variability in thetotal number of cancer cases reportedin 2004 at each of the nine Sutter Healthhospitals. Year 2004 overall case volumeranged from 359 at EMC to 1,937 atCPMC, for a total of 9,539 cases systemwide.Eighty-five percent of these cases(8,139) were newly diagnosed and/orreceived the first course of treatment atone of the nine Sutter centers. These aredesignated as “analytic” cases and allfurther analyses are restricted to thesedata.Figure 12004 Sutter Health Analytic Cancer CasesPatient Volume by class of CaseAGE AT DIAGNOSISOverallGenerally similar patterns were seen atall institutions, with the number of cancerpatients peaking in the 70–79 agerange. Almost 50% of cancer patientswere diagnosed in the 60–79 age range,and 83% were age 50 or over at thetime of diagnosis. The median age atdiagnosis was 65 years. The median ageranged from 62 (ABMC) to 71 (EMC).ABMC, SMCS and CPMC had theyoungest cancer patient populations,and EMC and MPHS had the oldest.These trends reflect differences in boththe underlying demographics of thecommunities served and the relativeincidence of the most prevalent cancersseen at each institution. The male cancerpatient population is slightly olderthan the female cancer patient population(median age is 67 vs. 64). Thesedata are consistent with those seen overthe last nine years in the Sutter Healthcancer patient population.Eric Gold, Oncology Analyst/ProgrammerSee page two for abbreviations forSutter Health institutions.1In order to be consistent with previous Sutter HealthCancer Programs Annual Reports, which included onlymalignant neoplasms, this analysis does not includebenign neoplasms of the brain and central nervoussystem, which are reportable in the state of California,beginning with cases diagnosed Jan. 1, 2001, and later.However, these cases have been included in the primarysite tables for each facility at the end of this report.2It is important to note that hospital cancer registry datareflect patients diagnosed and treated in the hospital,unlike population-based cancer registry data such asthose reported by the California Cancer Registry and atthe SEER registry of the National Cancer Institute, whichrepresent all patients diagnosed in a defined population. 2005 Annual Cancer Center Report — 2004 Statistical Review | 33

S t a t i s t i c a l O v e r v i e wStatisticalSutter Health 2004 Cancer Registry DataAGE DISTRIBUTION BYGENDER (Figure 2)MalesThe nine hospitals show modestdifferences. The greatest number ofcases fell into either the 60–69 agegroup (ABMC, MGH, SMCS) or intothe 70–79 age group (CPMC, EMC,MMC, MPHS, SMCS), resulting in anoverall parity for these two age groups(26% and 27%, respectively). Overall,53% of the males were diagnosed in the60–79 age range.FemalesOverall females show a flatter andsomewhat more varied distributionthan males. At ABMC and CPMC theage distribution peaked in the 50–59range, while EMC, MMC, MPHS, SMCand SRMC females peaked in the 70–79age range. MGH females were evenlydivided between the 50–59 and 70–79age ranges. Only 42% of the femaleswere diagnosed in the 60–79 age range,contrasting with 53% in males. Thesegender differences probably reflectvariations in the age at diagnosis forthe two most dominant gender-specificcancers: prostate and breast cancer (seeFigure 5, page 37). Within each gender,prostate and breast cancer account for25% and 39%, respectively, of all newlydiagnosed cases. The median age atdiagnosis for prostate cancer was 66 vs.58 for female breast cancer.Figure 22004 Sutter Health Analytic Cancer CasesAge Distribution by Gender 34 | 2005 Annual Cancer Center Report — 2004 Statistical Review

S t a t i s t i c a l O v e r v i e wOverviewSutter Health 2004 Cancer Registry DataGENDER RATIO (Figure 3)As seen in past years in the SutterHealth network, the female cancerpatient population is significantly largerthan the male population. Femalesaccount for 56% and males account for44% of the newly diagnosed cancersseen in 2004. This trend was observedat all institutions. The largest disparityin gender ratio was at EMC, SMCS andABMC, while gender proportions weremostly equal at MGH, SMC and SRMC.These differences are largely a reflectionof the relative incidence of male-specificcancers (mostly prostate) and femalespecificcancers (mostly breast, uterusand ovary). For example, SMCS has thehighest incidence of breast, uterine andovarian cancers relative to prostatecancer, while SMC, MGH and SRMChave the lowest incidence of breast,uterine and ovarian cancers relative toprostate cancer.It is important to note that the femaleto-maleratio in population-basedregistries such as the California CancerRegistry is 1–to–1, whereas our Sutterhospital-based registries record apreponderance of female patients.These differences are due to hospitalreferral patterns and the inherentnature of these two different types ofcancer registries.Figure 32004 Sutter Health Analytic Cancer CasesGender Ratio 2005 Annual Cancer Center Report — 2004 Statistical Review | 35

S t a t i s t i c a l O v e r v i e wStatisticalSutter Health 2004 Cancer Registry DataRACE/ETHNICITY (Figure 4)The distribution of patients by race/ethnic group reflects the diversity seenin the communities served by eachinstitution. The SMC cancer patientpopulation is the most ethnically diversewith the fewest Caucasians (51%)and large African-American (24%) andAsian 3 (19%) components. ABMC alsohas a large African-American component(23%), with SMC and ABMCtogether accounting for two-thirdsof the entire Sutter Health African-American cancer patient population.CPMC also has a relatively diversepatient population with the largestAsian component (24%). CPMC andSMC together account for nearly 60% ofthe Sutter Health Asian population. Arelatively large Hispanic component isseen at MMC (11%). The cancer patientpopulations at SRMC and MGH are theleast ethnically diverse (92% and 91%Caucasian, respectively).3Asian includes Asian and Pacific Islander.Figure 42004 Sutter Health Analytic Cancer CasesRace/Ethnicity 36 | 2005 Annual Cancer Center Report — 2004 Statistical Review

S t a t i s t i c a l O v e r v i e wOverviewSutter Health 2004 Cancer Registry DataTOP 10 PRIMARY CANCER SITES (Figure 5)The distribution of the most prevalent cancers seen in the Sutter Health network has changed very little over the past nine years.The top 10 cancer sites comprise nearly three-quarters of the newly diagnosed cancers seen in the Sutter Health network. Femalebreast cancer accounts for 22% of all cancers seen in the Sutter Health network. Lung (12%), prostate (11%), colorectal (10%) andnon-Hodgkin’s lymphoma (4%) account for 37% of cancers newly diagnosed in 2004. Some additional trends observed were:• Breast Cancer: Highest relative incidence seen at MGH (27%), and the lowest at SRMC and SMC (19% and 20%, respectively)• Lung Cancer: Highest relative incidence at MMC (19%), and the lowest at CPMC and MGH (8%)• Prostate Cancer: There are many possible factors that affect the relative incidence of prostate cancer at community hospitals.The relatively high incidence seen at SMC (20%) may be due to the fact that it has a relatively older underlying patientpopulation and a relatively large African-American component. A similarly high incidence at MGH (21%) may be explainedby socioeconomic factors leading to higher PSA screening penetrance and thus higher detection/overdetection of MarinCounty men with prostate cancer. SMCS had the lowest incidence (4%); in this case it appears that demographic factors donot play the major role. Instead, the low proportion of newly diagnosed prostate cases seen at SMCS is likely the result ofcommunity referral patterns. Many of the prostate cancer cases are diagnosed in physician offices and referred for treatmentat a large independent radiation oncology practice in the community. Appropriately, the SMCS cancer registry does notrecord these patients and the result is an under-representation of prostate cancer in their database.• Colorectal Cancer: Highest relative incidence at MPHS (13%) and the lowest at SMCS (8%)• Non-Hodgkin’s Lymphoma: Highest relative incidence at SMCS (6%) and the lowest at MGH (2%)• Bladder Cancer: Highest relative incidence at EMC and MGH (7%) and the lowest at CPMC (2%)• Pancreatic Cancer: Highest relative incidence at CPMC (7%) and the lowest at SMC (1%)• Uterine Cancer: Lowest relative incidence at SRMC (1%)• Renal Cancer: Highest relative incidence at MMC (4%)• Hepatic Cancer: Highest relative incidence at CPMC (7%)Figure 52004 Sutter Health Analytic Cancer CasesTop 10 Primary Cancer Sites (Overall) by Institution by Gender2005 Annual Cancer Center Report — 2004 Statistical Review | 37

S t a t i s t i c a l O v e r v i e wStatisticalRELATIVE INCIDENCE OF MAJOR INVASIVE CANCERS —COMPARISON WITH STATE AND NATIONAL ESTIMATES 4 (See Figure 6, next page)Sutter Health 2004 Cancer Registry DataOverall Sutter Health Compared with California and the United States:Oral, Lung, Colon & Rectum, Urinary, Leukemia/Lymphomas, Uterus and Ovary— Sutter Health was generally similar to statewide and national estimates.Female Breast — Slightly higher than seen in California and the U.S. (35% vs. 33% and 32%)Prostate — Lower than seen in California and the U.S. (25% vs. 32% & 33%)Pancreas — Slightly higher than seen in California and the U.S. (4% vs. 2%)Individual Sutter Health Institutions Compared with California and the United States:Oral— Relatively high rate in MMC males compared with California and the U.S.(6% vs. 3% for California and the U.S.)Lung — Relatively high rates in MMC and SMCS males compared with California and the U.S. (22% & 19% vs. 13%for California and the U.S.)— Relatively low rates in MGH, CPMC and MPHS males compared with California and the U.S.(8%, 9% & 10% vs. 13%)— Relatively high rates in SRMC, MMC and SMCS females compared with California and the U.S.(23%, 19% & 15% vs. 12%)— Relatively low rates in CPMC, MGH and SMC females compared with California and the U.S.(5% & 9% vs. 12%).Pancreas — Relatively high rate in CPMC males compared with California and the U.S. (7% vs. 2%)— Relatively high rate in CPMC females compared with California and the U.S. (8% vs. 2%)Colorectal — Relatively high rate in EMC males compared with California and the U.S. (14% vs. 11%)— Relatively high rate in MPHS females compared with California and the U.S. (14% vs. 10% & 11%)— Relatively low rate in SMCS females compared with California and the U.S. (6% vs. 10% & 11%)Urinary— Relatively high rates in MPHS, MGH and EMC males compared with California and the U.S.(15% & 14% vs. 9% & 10%)— Relatively low rates in ABMC, CPMC and SMC males compared with California and the U.S.(6% vs. 9% & 10%)— Relatively high rate in MGH females compared with California and the U.S. (8% vs. 4% & 5%)Leukemia/Lymphomas— Relatively high rates in ABMC and SMCS males compared with California and the U.S. (12% vs. 8%).— Relatively low rates in MGH and MMC males compared with California and the U.S. (5% vs. 8%)— Relatively high rate in ABMC females compared with California and the U.S. (10% vs. 6% & 7%)Uterus — Relatively low rate at SRMC compared with California and the U.S. (2% vs. 5% & 6%)Ovary — Relatively low rate at SMC compared with California and the U.S. (1% vs. 4%)Female Breast— MGH and MPHS had relatively high rates compared with California and the U.S. Ranges from 46% atMGH down to 31% at SRMC (vs. 33% for California and 32% for U.S.)Prostate— The most variable of any of the major sites examined. Ranges from 44% at MGH down to 10% at SMCS(vs. 32% & 33% for California and the U.S.)4Both state and national estimates are derived from NCI SEER data published by the American Cancer Society.38 | 2005 Annual Cancer Center Report — 2004 Statistical Review

S t a t i s t i c a l O v e r v i e wOverviewSutter Health 2004 Cancer Registry Data Figure 62004 Sutter Health Analytic Cancer CasesRelative Incidence of Major InvasiveCancers — Comparison with State andNational Estimates2005 Annual Cancer Center Report — 2004 Statistical Review | 39

Sutter Health 2004 Cancer Registry DataFigure 72004 Sutter Health Analytic Cancer Casesgeographic Distribution7,943 of 8,139 Cases Displayed (98%)ABMC921 Cases Displayed (98%)MPHS908 Cases Displayed (99%)SMCS1,284 Cases Displayed (98%)CPMC1,572 Cases Displayed (94%)EMC318 Cases Displayed (100%)SRMC605 Cases Displayed (98%)MGH610 Cases Displayed (99%)MMC835 Cases Displayed (99%)SMC605 Cases Displayed (98%)40 | 2005 Annual Cancer Center Report — 2004 Statistical Review

S t a t i s t i c a l O v e r v i e wOverviewSutter Health 2004 Cancer Registry DataGeographic Distribution (Figures 7 and 8)Figure 7 displays 7,943 (98%) of the 8,139 analytic cases examined in this analysis,mapped by nine digit zip code. 5 In 2004, 8,015 (98.5%) of the cases were diagnosedin California, 121 (1.5%) were diagnosed in the United States outside California, andthree (0.04%) were diagnosed outside of the United States. The distribution of casesby California county can be summarized as follows (see Figure 8 below):ABMC – 67% Alameda County, 27% Contra Costa CountyCPMC – 58% San Francisco County, 8% San Mateo County, 6% Marin CountyEMC – 94% Alameda CountyMGH – 86% Marin County, 6% Sonoma CountyMMC – 87% Stanislaus CountyMPHS – 94% San Mateo CountySMC – 77% Alameda County, 13% Contra Costa CountySMCS – 67% Sacramento County, 9% Placer County, 8% Yolo CountySRMC – 63% Placer County, 25% Sacramento County5Cases were mapped using a process known as“geocoding,” whereby U.S. Postal Service data are usedto assign nine digit zip codes for each case; these arethen matched to a precise latitude/longitude using U.S.Census Bureau TIGER/ZIP data files for California.The cases are then mapped graphically based on theirgeographic coordinates using Geographic InformationSystem (GIS) software.2004 Sutter Health Analytic Cancer CasesDistribution by County,Sutter HealthAla me da Co .ABMC66.5CPMC5.2EMC94.3MGH MMC MPHS SMC SMCS SRMC0.50.00.976.7 0.20.0Sutter21.1S acr a me n to Co .0.11.30.00.30.00.00.167.025.313.0S a n F r a ncisco Co .0.558.20.00.80.01.70.30.00.012.4S a n Mate o Co .0.27.80.00.30.093.71.10.00.212.3S t a nislaus Co .0.00.40.00.087.00.10.20.20.09.1Ma r in Co .0.16.00.086.00.00.10.20.00.07.8Place r Co .0.00.40.00.00.00.00.08.963.16.3Con t r a Cost a Co .27.22.83.81.10.10.413.10.00.25.5Y ol o C o .0.20.20.00.00.00.00.07.50.61.3Sonoma Co .0.32.80.06.40.00.20.00.20.01.2O t he r C A3.511.11.94.112.82.26.714.99.08.5Outside C A1.33.80.00.50.10.71.51.11.61.5%%%%%%%%%%2005 Annual Cancer Center Report — 2004 Statistical Review | 41

primary site tablesAlta Bates Summit Medical Center – Alta Bates Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.42 | 2005 Annual Cancer Center Report — 2004 Statistical Review

primary site tablesCalifornia Pacific Medical Center Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.2005 Annual Cancer Center Report — 2004 Statistical Review | 43

primary site tablesEden Medical Center Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.44 | 2005 Annual Cancer Center Report — 2004 Statistical Review

primary site tablesMarin General Hospital Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.2005 Annual Cancer Center Report — 2004 Statistical Review | 45

primary site tablesMemorial Medical Center Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.46 | 2005 Annual Cancer Center Report — 2004 Statistical Review

primary site tablesMills-Peninsula Health Services Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.2005 Annual Cancer Center Report — 2004 Statistical Review | 47

primary site tablesAlta Bates Summit Medical Center – Summit Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.48 | 2005 Annual Cancer Center Report — 2004 Statistical Review

primary site tablesSutter Medical Center, Sacramento Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.2005 Annual Cancer Center Report — 2004 Statistical Review | 49

primary site tablesSutter Roseville Medical Center Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.50 | 2005 Annual Cancer Center Report — 2004 Statistical Review

primary site tablesSutter Health network Legend: N/R = Not recorded Includes analytic cases that could not be staged because no AJCC staging exists for the particular primary site or histologic type. This includes mosthematopoetic cancers (leukemia, myeloma, etc.), endocrine cancers, cancers of the brain and nervous system, sarcomas, cancers of the peritoneum, thymoma, and cancers where theprimary site is ill-defined or unknown.Abbreviations: A = analytic; N/A = non-analytic; M = male; F = female Tabulations for stage at diagnosis include analytic cases only.2005 Annual Cancer Center Report — 2004 Statistical Review | 51

www.cancer.sutterhealth.orgPlease refer your patients to the website for patient education videos on Breast and Prostate Cancer.www.cancer.sutterhealth.org/information/videointro.html52 | 2005 Annual Cancer Center Report — 2004 Statistical Review

Sutter Health ACoS Cancer ProgramsAlta Bates Medical CenterCalifornia Pacific Medical CenterEden Medical CenterMarin General HospitalMemorial Medical CenterMills-Peninsula Health ServicesSummit Medical CenterSutter Medical Center, SacramentoSutter Roseville Medical CenterSutter Solano Medical Center