CAROLINAS MEDICAL CENTER CANCER NETWORK

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1 2 1 A N N U A L R E P O R T (USING 29 STATISTICAL DATA) C A R O L I N A S M E D I C A L C E N T E R CAROLINAS MEDICAL CENTER CANCER NETWORK CAROLINAS MEDICAL CENTER CAROLINAS MEDICAL CENTER-MERCY CAROLINAS MEDICAL CENTER-PINEVILLE CAROLINAS MEDICAL CENTER-UNIVERSITY

2 Cancer Committee Chairman s Report Cancer Liaison Physician s Report Cancer Committee Membership Cancer Conferences General Tumor Board CMC Network Leading Sites - 29 Estimate Cancer Data - Network Cancer Data Age by Sex Distribution Race Distribution TNM Stage Distribution Stage by Sex State & National Comparison County Distribution Carolinas Medical Center Oncology Quality Assurance Cancer Data Age by Sex Distribution Race Distribution TNM Stage Distribution Stage by Sex State & National Comparison County Distribution Carolinas Medical Center-Mercy Cancer Data Age by Sex Distribution Race Distribution TNM Stage Distribution Stage by Sex State & National Comparison County Distribution Carolinas Medical Center-University Cancer Data Age by Sex Distribution Race Distribution TNM Stage Distribution Stage by Sex State & National Comparison County Distribution Carolinas Medical Center-Pineville Cancer Data Age by Sex Distribution Race Distribution TNM Stage Distribution Stage by Sex State & National Comparison County Distribution Major Site Report: Cervix Major Site Report Race/Ethnicity of Cervix Uteri Cancer Stage of Cervix Uteri Cancer Age Group of Cervix Uteri Cancer Histology of Cervix Uteri Cancer First Course Treatment of Cervix Uteri Cancer Observed Survival for Cases Diagnosed in 23 Data Observed Survival for Cases Diagnosed Data Contact Information

3 Cancer Committee Chairman s Report Carolinas Medical Center s Blumenthal Cancer Center remains at the forefront of the fight against cancer. Within the CMC facilities in Charlotte, Carolinas Medical Center continues to serve as the largest provider of cancer services for Carolinas HealthCare System. Importantly, the development and incorporation of CMC- Mercy, CMC-Pineville and CMC-University within the cancer realm has increased our total number of new cancer cases being accessioned through our sister facilities to nearly 4,6 cases. Blumenthal Cancer Center is committed to maintaining our position as a leader in cancer care. We are proud of the care we provide, and excited about new opportunities to help more patients and families in the Carolinas and beyond. We value your support and partnership in this important work. JEFFREY S. KNEISL, MD Our Cancer Liaison Report defines some of the specific achievements for 29. Below, I have included some of the goals that were reached by the CMC Cancer Committee during 21, as well as the goals that were set for 211. The American College of Surgeons requires all accredited cancer facilities to designate achievement goals in several domains each year. These domains include clinical, community outreach, quality improvement, and cancer programmatic goals. During 21, the Cancer Committee achieved four goals: (1) Clinical: Evaluate and amplify molecular diagnostic testing (2) Community Outreach: Evaluate patient and family centered care opportunities such as expansion of ACS programs and the development of a Family Advisory Council (3) Quality Improvement: Develop QI survey of awareness of NCCN guidelines in cancer network (4) Programmatic: Evaluate the feasibility of implementation of an oncology-specific electronic medical record For 211, the Cancer Committee established the following goals: (1) Clinical: Develop and expand patient navigator program (2) Community Outreach: Implement Patient Family Advisory Council (3) Quality Improvement: Implement QI survey of NCCN guidelines and clinical stage of top five sites at all network facilities (4) Programmatic: Unification of cancer registry operations among CHS facilities Our achievements in 21 were substantial and continue to demonstrate the dedication of our team. Our wonderful staff, nurses and physicians continuously strive to provide excellent patient care and service to patients and their families affected by cancer in our region. Respectfully submitted, Jeffrey S. Kneisl, MD, FACS Medical Director, Blumenthal Cancer Center 2

4 Cancer Liaison Physician s Report The cancer program at Carolinas Medical Center continues to expand at a remarkable pace. Our 3,416 accessioned cases in 29 were a full 7.6 percent increase over those accessioned in 28. This continues a trend seen over many years. Many of our readers may not be aware that accession cases do not include several hundred additional cancer cases that are seen in consultation for second opinions, or completing cancer care that may have been initiated elsewhere. As a network program, it is also important to note that 1,183 other cases were diagnosed at CMC-Pineville, CMC-Mercy and CMC-University. All total the CMC Cancer Network accessioned 4,599 cases. RICHARD L. WHITE, JR., MD Our mix of patients reflects the national trends that one would expect with the most common diagnoses representing breast, lung and prostate cancer. We also have substantial numbers of patients who have been cared for with GYN malignancies, melanoma, kidney cancer and brain cancer, given our notable programs in the care of patients with these specific diagnoses. Of our 3,416 patients, 343 were recruited to clinical trials. This continues our strong presence in research and our emphasis on clinical trials and the acquisition of tissue for further study. This 1 percent stands in stark contrast to the national average for enrollment in clinical trials of approximately 4 percent. We continue to accrue well to both industry and cooperative group trials. In addition, 67 patients participated in Total Cancer Care TM, a research partnership with H. Lee Moffitt Cancer Center and Research Institute. Community outreach under the leadership of Kevin Platé of the cancer center has remained at a very high level. Carolinas HealthCare System was involved in 55 community events that allowed interaction with 82,14 participants. Many of these events are combined efforts with the American Cancer Society continuing our goal to develop stronger partnerships between the Cancer Committee and the American Cancer Society. We are proud of these efforts as we continue our work as a network accredited program. It is clear that cancer care in the Charlotte region continues to move forward allowing better care for patients in our region. Richard L. White, Jr., MD, FACS Cancer Liaison Physician Chief, Division of Surgical Oncology 3

5 Cancer Committee Membership Asim Amin, MD Vice Chair Jeff Aho Lisa Amacker-North, MS Lisa Barber, RN John Barkley, MD Emily Bellard, CNS Ross Bellavia, MD Wendy Brick, MD Rose Bryan Rachel Burns, RD Benjamin Calhoun, MD Teresa Flippo, MD Kris Gaston, MD Nehemie Georges Sharon Gilkerson, CTR Andrew Gilman, MD Debra Godfrey Michael Haake, MD QI Chair Rita Harmon-Law Chris Hummer Scott Kerr Mark King Gwen Lambert, RN Nancy Lane Tracia Lewis, ACS Spencer Lilly Steven Limentani, MD Bob Massengill Andrea Mauth Katie Mileham, MD Joshua Miller, MD Jeffrey S. Kneisl, MD Chairman Scott Moroney Reza Nazemzadeh, MD QI Chair - Mercy Javier Oesterheld, MD Sridhar Pal, MD QI Chair - Pineville Cathy Parris, RN Kevin Platé Heather Presley Vishwa Raj, MD Chan Roush Stuart Salmon, MD QI Chair - University Jonathan Salo, MD Terry Sarantou, MD Gail Satterfield Grace Sauzier, RN David Tait, MD Paige Tedder, RHIT, CTR Suzanne Thibodeau, RN Raymond Tsao, MD Meg Turner, MSW Allison Walls, PharmD Eric Wang, MD Ritu Ward Carol Weida, MD Quality Control Coordinator Brook White, MS Patricia White, MD Richard L. White, Jr., MD ACoS Liasion Physician Phyllis Wingate-Jones Warden Woodard, MD 4

6 Cancer Conferences Cancer conferences conducted under the auspices of the Cancer Committee include: Breast Tumor Board (Teleconferenced) Bone and Soft Tissue Tumor Conference Brain Tumor Conference (Teleconferenced) General Tumor Board (Teleconferenced) Genitourinary Conference GI Tumor Planning Conference Gynecology Tumor Board (Teleconferenced) Head and Neck Conference (Teleconferenced) Immunotherapy/Melanoma Tumor Conference Lung Tumor Conference Lung Tumor Planning Conference Small Tumor Kidney Conference Urology Conference All conferences offer continuing medical education (CME) credit through the Area Health Education Center (AHEC). Three of these conferences are coordinated by Cancer Data Services by Janice Wallace. Jonathan Salo, MD, serves as cancer conference coordinator and works with physicians to schedule case presentations. We continue to teleconference our General Tumor Board Conference between CMC, CMC- Mercy, CMC-Pineville and CMC-University. We have also had participation from Wallace Thompson Hospital in Union, SC. We continue to use web-based video conferencing for the Breast Tumor Board and the Head and Neck Conference. This technology allows for both interactive conferencing with users over the Internet and allows archiving of presentations for later review. Dr. Salo updated the Cancer Committee during the year regarding case presentations and multidisciplinary attendance at conferences by diagnostic radiology, interventional radiology, medical oncology, pathology, radiation oncology and surgery. We are making plans to expand the use of video conferencing for cancer conferences, both within CMC facilities in Charlotte and with Carolinas Physicians Network (CPN) and area physicians. 5

7 General Tumor Board CMC Network SITE 29 Abdomen / Gastric 25 Adrenal 5 Adrenocortical 2 Ampullary 1 Aplastic Anemia 1 Anus / Anal 11 Appendix 1 Atypical Dermal 1 Bladder 65 Bones/Soft Tissue 468 Breast 145 Carcinoid 7 Cervix 1 Cholangiocarcinoma 6 Colon 46 Colorectal 3 Didactic 12 Duodenal 1 Endometrium 3 Esophagus 9 Extra Adrenal Parganglioma 1 Fallopian Sarcoma 1 Gallbladder 2 Gastrinoma 1 GE Junction 2 Germ Cell Tumor 1 GI Stromal 1 Gist 5 HCC 3 Hepatic Hemangioma 1 Hepatoma 1 Hodgkin s 2 Hyperleukocytosis 1 IPMN 2 Insulinoma 2 Islet Cell 2 Ivc Sarcoma 1 Jejenum 2 Kidney 297 Klaskin Tumor 1 Liver 19 SITE 29 Lung 65 Lymph 7 Malignant PE Coma 1 Malignant Temporal Lobe 1 MDS 1 Mediastinal 4 Mesenteric Mass 1 Mesothelioma 1 Metastatic Crc 1 Multiple Primary Cancer 1 Myxoid Liposarcoma 1 Neck 1 Neuroendoctrine 2 Ocular Melanoma 1 Oral Cavity 2 Ovary 7 Ovarian Thrombosis 1 Pancreas 39 Parotid 2 Pelvic Sarcoma 1 Pelvic 1 Pelvis 1 Penis 2 Pericardua Cyst 1 SITE 29 Plasmacytoma 1 PHN 1 Portal Venous Obst 1 Positive BRCA 1 Prostate 23 Renal Cell 46 Retroperitoneum 2 Rectosigmoid 1 Rectum 22 Sarcoma 1 Scrotum 1 Skin 228 Small Bowel 2 Stomach 2 Testis 12 Thoracic Synovial 1 Thymus 1 Thyroid 5 Tongue 3 Uterine 3 Uterus 1 Urothelial 1 Vulva 3 Totals

8 Leading Sites of New Cases and Deaths 29 Estimates Estimated New Cases* Estimated Deaths Male Female Male Female Prostate Breast 192,28 (25%) 192,37 (27%) Lung & Bronchus Lung & Bronchus 116,9 (15%) 13,35 (14%) Colon & Rectum Colon & Rectum 75,59 (1%) 71,38 (1%) Urinary Bladder Uterine Corpus 52,81 (7%) 42,16 (6%) Melanoma of the Skin Non-Hodgkin Lymphoma 39,8 (5%) 29,99 (4%) Non-Hodgkin Melanoma Lymphoma of the Skin 35,99 (5%) 29,64 (4%) Kidney & Renal Pelvis Thyroid 35,43 (5%) 27,2 (4%) Leukemia Kidney & Renal Pelvis 25,63 (3%) 22,33 (3%) Oral Cavity & Pharynx Ovary 25,24 (3%) 21,55 (3%) Pancreas Pancreas 21,5 (3%) 21,42 (3%) All Sites All Sites 766,13 (1%) 713,22 (1%) Lung & Bronchus Lung & Bronchus 88,9 (3%) 7,49 (26%) Prostate Breast 27,36 (9%) 4,17 (15%) Colon & Rectum Colon & Rectum 25,24 (9%) 24,68 (9%) Pancreas Pancreas 18,3 (6%) 12,21 (6%) Leukemia Ovary 12,59 (4%) 14,6 (5%) Liver & Non-Hodgkin Intrahepatic Bile Duct Lymphoma 12,9 (4%) 9,67 (4%) Esophogus Leukemia 11,49 (4%) 9,28 (3%) Urinary Bladder Uterine Corpus 1,18 (3%) 7,78 (3%) Non-Hodgkins Liver & Lymphoma Intrahepatic Bile Duct 9,83 (3%) 6,7 (2%) Kidney & Renal Pelvis Brain & Nervous System 8,16 (3%) 5,59 (2%) All Sites All Sites 292,54 (1%) 269,8 (1%) 29, American Cancer Society, Inc. Surveillance and Health Policy Research * Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary/bladder. 7

9 29 Tumor Board Registry Statistics - Network REVIEW OF ANALYTIC ACCESSIONS SEX TNM STAGE Total Male Female O I II III IV UNK N/A All Sites Oral Cavity Lip Tongue Oropharynx Hypopharynx Other Digestive System Esophagus Stomach Colon Rectum Anus/Anal Canal Liver Pancreas Other Respiratory System Nasal/Sinus Larynx Lung/Bronchus Other Blood & Bone Marrow Leukemia Multiple Myeloma Other Bone Connect/Soft Tissue Skin Melanoma Other

10 SEX TNM STAGE Primary Site Total Male Female O I II III IV UNK N/A Breast Female Genital Cervis Uteri Corpus Uteri Ovary Vulva Other Male Genital Prostate Testis Other Urinary System Bladder Kidney/Renal Other Brain & CNS Brain (Benign) Brain (Malignant) Other Endocrine Thyroid Other Lymphatic System Hodgkin's Disease Non-Hodgkin's Unknown Primary Other/Ill-Defined

11 AGE DISTRIBUTION - NETWORK Age Range Male Female TOTALS AGE RANGE Male Female RACE DISTRIBUTION - NETWORK White Black Other Race Cases Percent White % Black % Other 246 6% TOTAL % 1

12 CASES TNM STAGE DISTRIBUTION - NETWORK TNM Stage NBR Cases Percent 35 7% I % II % III 49 12% IV % UNK 386 9% N/A % TOTAL % I II III IV UNK N/A TNM STAGE CASES STAGE BY SEX - NETWORK Stage Male Female I II III IV UNK N/A TOTALS I II III STAGE IV UNK N/A Male Female 11

13 STATE AND NATIONAL COMPARISONS - NETWORK PERCENTAGE B r east Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC Network NC Estimates US Estimates Type CMC NC US TOTAL 4,255 42,27 1,479,35 percent of total Breast 18% 13% 13% Lung 9% 16% 15% Prostate 9% 7% 13% Colorectal 6% 1% 1% Bladder 3% 4% 5% NH Lymphoma 4% 4% 4% Corpus Uteri 4% 2% 3% Melanoma 8% 5% 5% Leukemia 3% 3% 3% Cervis 2% 1% 1% All Others 34% 34% 29% 12

14 COUNTY DISTRIBUTION OF CANCER CASES - NETWORK 1. Mecklenburg York, SC Union Gaston Cabarrus Lincoln Cleveland Lancaster, SC Iredell Rowan Catawba Stanly Burke Anson Rutherford Chester, SC Caldwell Chesterfield, SC Richmond Montgomery Cherokee, SC Union, SC Watauga Greenville, SC Spartanburg, SC Ashe Buncombe Marlboro, SC Richland, SC 6 3. Lexington, SC Alexander Brunswick Florence, SC Kershaw, SC Marion, SC Sumter, SC Haywood Moore New Hanover 4 4. Robeson Scotland Wilkes Horry, SC Forsyth Guilford Henderson Polk Surry Alamance 2 5. Aiken, SC Beaufort, SC Charleston, SC Cumberland Davidson Durham Oconee, SC Orangeburg, SC Pickens, SC Macon 2 6. Transylvania Anderson, SC Avery Carteret Davie Newberry, SC Graham Saluda, SC Hertford Lee 1 7. McDowell Madison Nash Pender Person Pitt Randolph Rockingham Sampson Stokes 1 8. Swain Wayne 1 North Carolina 3539 South Carolina 672 Out of State 51 Total NORTH CAROLINA SOUTH CAROLINA OTHER OUT OF STATE TOTAL

15 Quality Assurance Report I am pleased to report a busy and successful year of effort on the part of the Quality Assurance (QA) Committee. In addition to the two clinical practice guideline (CPG) studies that evaluate practice patterns and compare to the National Cancer Center Network Guidelines, other in-house reviews were accomplished. Data was assimilated for presentation to the ACOS surveyors for the successful accreditation of our cancer network. The first CPG study performed was an evaluation of the utilization of postoperative radiotherapy, and chemotherapy secondarily, in appropriate stage III and non-metastatic stage IV head and neck cancers. Of the patients reviewed, 11 MICHAEL HAAKE, MD matched the criteria for evaluation, and seven of these received the recommended adjuvant therapy. The reason for not receiving the therapy in the other patients included lack of patient compliance with follow up, refusal of treatment and a patient with dementia deemed inappropriate for therapy. No recommendations of change in practice were made, and it was felt that this recently published guideline had been well incorporated by the physicians taking care of these patients. The second CPG study looked at the utilization of endoscopic ultrasound in appropriate non-metastatic esophageal patients. It was evident on this review that this technology, though only recently added to the diagnostic capability in the CHS system, was being used per the NCCN recommendations. Between 27 and 28, the use of this technology had tripled. The attractiveness of CHS to specialists trained in new techniques allows for rapid incorporation of these techniques into the cancer program. The equip studies of utilization of chemotherapy, hormonal agents and radiotherapy in the adjuvant treatment of breast cancer is an ongoing review, and the CHS network continues to report greater than 9 percent appropriate use of such therapies. In the ongoing review of the Cancer Program Practice Profile Reports (CP3R) looking at issues of colon cancer diagnostic and adjuvant therapy issues (lymph node retrieval, use of adjuvant chemotherapy), CHS maintains greater than 9 percent acceptable practice rate. A review of breast cancer sentinel lymph node pathology was undertaken by the pathology department and another study reviewed the accuracy of thyroid FNA biopsy material. These studies noted the accuracy rate was well in line with the prevailing national standards. The QA Committee tallies improvements that have occurred in the cancer program and addresses future improvements. It was determined that the AJCC staging and the NCCN guidelines for a given oncologic problem presented at cancer conferences would be emphasized and this would be recorded as accomplished at that conference. The General Tumor Board and the Breast Conference were in charge of initiating this requirement. Dr. Salo sent a letter to the heads of other cancer conferences to launch this activity in the future. A major improvement of note that was tallied by the QA Committee included the opening of Pineville Radiation Therapy Center, a major addition in the oncologic care offered in this region. Other improvements included a nurse navigator hired to aid in guiding lung cancer patients through their necessary clinics, tests and follow-up and the construction of templates used by the radiology department 14

16 for reporting cancer related imaging results. Another improvement was the creation of order sets for chemotherapy administration for breast, GI, lung cancer and an order set for febrile neutropenia. With the announcement of Levine Cancer Institute, the QA Committee anticipates the opportunity for an exciting broadening role in helping to monitor and address cancer care quality issues in the future. I am touched by the great efforts of the QA Committee members and registry staff this past year, and I appreciate the physicians who enthusiastically agreed to aid in helping analyze and present the studies done this year. Quality Assurance Chairmen Michael Haake, MD Stuart Salmon, MD Sridhar Pal, MD Assurance Director Quality Assurance Chair Quality Assurance Chair CHS Oncology Quality CMC-Pineville CMC-University 15

17 29 Tumor Board Registry Statistics - CMC REVIEW OF ANALYTIC ACCESSIONS SEX TNM STAGE Total Male Female O I II III IV UNK N/A All Sites Oral Cavity Lip Tongue Oropharynx Hypopharynx Other Digestive System Esophagus Stomach Colon Rectum Anus/Anal Canal Liver Pancreas Other Respiratory System Nasal/Sinus Larynx Lung/Bronchus Other Blood & Bone Marrow Leukemia Multiple Myeloma Other Bone Connect/Soft Tissue Skin Melanoma Other

18 SEX TNM STAGE Primary Site Total Male Female O I II III IV UNK N/A Breast Female Genital Cervix Uteri Corpus Uteri Ovary Vulva Other Male Genital Prostate Testes Other Urinary System Bladder Kidney/Renal Other Brain & CNS Brain (Benign) Brain (Malignant) Other Endocrine Thyroid Other Lymphatic System Hodgkin s Disease Non-Hodgkin s Unknown Primary Other/Ill Defined

19 AGE DISTRIBUTION - CMC Age Range Male Female TOTALS AGE RANGE Male Female RACE DISTRIBUTION - CMC White Black Other Race Cases Percent White % Black % Other 67 2% TOTAL % 18

20 CASES TNM STAGE DISTRIBUTION - CMC TNM Stage NBR Cases Percent 238 7% I % II % III 42 12% IV 48 14% UNK 318 9% N/A 53 14% TOTALS % I II III IV UNK N/A TNM STAGE CASES STAGE BY SEX - CMC Stage Male Female I II III IV UNK N/A TOTALS I II III STAGE IV UNK N/A Male Female 19

21 STATE AND NATIONAL COMPARISONS - CMC PERCEN TAGE B r east Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC Main NC Estimates US Estimates Type CMC NC US TOTAL 3,481 42,27 1,479,35 percent of total Breast 19% 13% 13% Lung 9% 16% 15% Prostate 7% 7% 13% Colorectal 5% 1% 1% Bladder 2% 4% 5% NH Lymphoma 3% 4% 4% Corpus Uteri 5% 2% 3% Melanoma 9% 5% 5% Leukemia 3% 3% 3% Cervis 2% 1% 1% All Others 36% 34% 29% 2

22 COUNTY DISTRIBUTION OF CANCER CASES - CMC 1. Mecklenburg York, SC Union Gaston Cabarrus Cleveland Lincoln Iredell Lancaster, SC Rowan Catawba Stanly Burke Rutherford Anson Caldwell Chester, SC Richmond Chesterfield, SC Montgomery Cherokee, SC Watauga Greenville, SC Spartanburg, SC Ashe Marlboro, SC Richland, SC Union, SC Buncombe 5 3. Lexington, SC Alexander Brunswick Florence, SC Kershaw, SC Haywood Moore New Hanover Robeson Scotland 4 4. Forsyth Marion, SC Guilford Sumter, SC Henderson Polk Surry Wilkes Aiken, SC Alamance 2 5. Beaufort, SC Charleston, SC Cumberland Horry, SC Davidson Durham Orangeburg, SC Pickens, SC Macon Transylvania 2 6. Anderson, SC Avery Carteret Fairfield, SC Davie Newberry, SC Oconee, SC Graham Saluda, SC Hertford 1 7. Lee McDowell Madison Nash Pender Person Randolph Rockingham Sampson Stokes 1 8. Swain Wayne 1 North Carolina 2938 South Carolina 496 Out of State 46 Total NORTH CAROLINA SOUTH CAROLINA OTHER OUT OF STATE TOTAL

23 29 Tumor Board Registry Statistics - CMC-Mercy REVIEW OF ANALYTIC ACCESSIONS SEX TNM STAGE Total Male Female O I II III IV UNK N/A All Sites Oral Cavity Lip Tongue Oropharynx Hypopharynx Other Digestive System Esophagus Stomach Colon Rectum Anus/Anal Canal Liver Pancreas Other Respiratory System Nasal/Sinus Larynx Lung/Bronchus Other Blood & Bone Marrow Leukemia Multiple Myeloma Other Bone Connect/Soft Tissue Skin Melanoma Other 22

24 SEX TNM STAGE Primary Site Total Male Female O I II III IV UNK N/A Breast Female Genital Cervis Uteri Corpus Uteri Ovary Vulva Other Male Genital Prostate Testis Other Urinary System Bladder Kidney/Renal Other Brain & CNS Brain (Benign) Brain (Malignant) Other Endocrine Thyroid Other Lymphatic System Hodgkin's Disease Non-Hodgkin's Unknown Primary Other/Ill-Defined

25 AGE DISTRIBUTION - CMC-MERCY Age Range Male Female TOTALS AGE RANGE Male Female RACE DISTRIBUTION - CMC-MERCY White Black Other Race Cases Percent White % Black 5 26% Other 1 5% TOTAL 195 1% 24

26 TNM STAGE DISTRIBUTION - CMC-MERCY CASES TNM Stage NBR Cases Percent 14 7% I 44 23% II 19 1% III 36 18% IV 36 18% UNK 14 7% N/A 32 16% TOTAL 195 1% I II III IV UNK N/A TNM STAGE CASES STAGE BY SEX - CMC-MERCY Age Range Male Female TOTALS I II III STAGE IV UNK N/A Male Female 25

27 STATE AND NATIONAL COMPARISONS - CMC-MERCY PERCENTAGE B r east Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC-Mercy NC Estimates US Estimates Type CMC NC US TOTAL ,27 1,479,35 percent of total Breast 2% 13% 13% Lung 29% 16% 15% Prostate 5% 7% 13% Colorectal 25% 1% 1% Bladder 5% 4% 5% NH Lymphoma 3% 4% 4% Corpus Uteri % 2% 3% Melanoma 2% 5% 5% Leukemia 2% 3% 3% Cervis % 1% 1% All Others 29% 34% 29% 26

28 COUNTY DISTRIBUTION OF CANCER CASES - CMC-MERCY 1. Mecklenburg Cabarrus Iredell 2 2. York, SC Lincoln Burke 1 3. Gaston 9 8. Stanly Cleveland 1 4. Union 7 9. Catawba Richmond 1 5. Anson 5 1. Chesterfield, SC Wilkes 1 North Carolina 177 South Carolina 16 Out of State 2 Total NORTH CAROLINA SOUTH CAROLINA OTHER OUT OF STATE TOTAL

29 29 Tumor Board Registry Statistics - CMC-University REVIEW OF ANALYTIC ACCESSIONS SEX TNM STAGE Total Male Female O I II III IV UNK N/A All Sites Oral Cavity Lip Tongue Oropharynx Hypopharynx Other Digestive System Esophagus Stomach Colon Rectum Anus/Anal Canal Liver Pancreas Other Respiratory System Nasal/Sinus Larynx Lung/Bronchus Other Blood & Bone Marrow Leukemia Multiple Myeloma Other Bone Connect/Soft Tissue Skin Melanoma Other 28

30 SEX TNM STAGE Primary Site Total Male Female O I II III IV UNK N/A Breast Female Genital Cervis Uteri Corpus Uteri Ovary Vulva Other Male Genital Prostate Testis Other Urinary System Bladder Kidney/Renal Other Brain & CNS Brain (Benign) Brain (Malignant) Other Endocrine Thyroid Other Lymphatic System Hodgkin's Disease Non-Hodgkin's Unknown Primary Other/Ill-Defined

31 AGE DISTRIBUTION - CMC-UNIVERSITY Age Range Male Female TOTALS AGE RANGE Male Female RACE DISTRIBUTION - CMC-UNIVERSITY White Black Other Race Cases Percent White 26 53% Black % Others 38 1% TOTAL 387 1% 3

32 CASES TNM STAGE DISTRIBUTION - CMC-UNIVERSITY I II III IV UNK N/A TNM STAGE TNM Stage NBR Cases Percent 2 5% I 62 16% II % III 4 1% IV 54 14% UNK 38 1% N/A 28 7% TOTAL 387 1% CASES STAGE BY SEX - CMC-UNIVERSITY Age Range Male Female 12 8 I II 1 45 III IV 34 2 UNK N/A TOTALS I II III STAGE IV UNK N/A Male Female 31

33 STATE AND NATIONAL COMPARISONS - CMC-UNIVERSITY PERCENTAGE B r east Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC-University NC Estimates US Estimates Type CMC NC US TOTAL ,27 1,479,35 percent of total Breast 23% 13% 13% Lung 1% 16% 15% Prostate 28% 7% 13% Colorectal 8% 1% 1% Bladder 4% 4% 5% NH Lymphoma 4% 4% 4% Corpus Uteri 1% 2% 3% Melanoma 1% 5% 5% Leukemia 2% 3% 3% Cervis % 1% 1% All Others 19% 34% 29% 32

34 COUNTY DISTRIBUTION OF CANCER CASES - CMC-UNIVERSITY 1. Mecklenburg Union Lancaster, SC 1 2. Cabarrus Cleveland Oconee, SC 1 3. Gaston Catawba Pitt 1 4. Iredell 8 1. Rowan Stokes 1 5. Lincoln Stanly 2 6. York, SC Chester, SC 1 North Carolina 372 South Carolina 1 Out of State 5 Total NORTH CAROLINA SOUTH CAROLINA OTHER OUT OF STATE TOTAL

35 29 Tumor Board Registry Statistics - CMC-Pineville REVIEW OF ANALYTIC ACCESSIONS SEX TNM STAGE Total Male Female O I II III IV UNK N/A All Sites Oral Cavity Lip Tongue Oropharynx Hypopharynx Other Digestive System Esophagus Stomach Colon Rectum Anus/Anal Canal Liver Pancreas Other Respiratory System Nasal/Sinus Larynx Lung/Bronchus Other Blood & Bone Marrow Leukemia Multiple Myeloma Other Bone Connect/Soft Tissue Skin Melanoma Other

36 SEX TNM STAGE Primary Site Total Male Female O I II III IV UNK N/A Breast Female Genital Cervis Uteri Corpus Uteri Ovary Vulva Other Male Genital Prostate Testis Other Urinary System Bladder Kidney/Renal Other Brain & CNS Brain (Benign) Brain (Malignant) Other Endocrine Thyroid Other Lymphatic System Hodgkin's Disease Non-Hodgkin's Unknown Primary Other/Ill-Defined

37 AGE DISTRIBUTION - CMC-PINEVILLE Age Range Male Female TOTAL AGE RANGE Male Female RACE DISTRIBUTION - CMC-PINEVILLE White Black Other Race Cases Percent White % Black 87 14% Other 47 8% TOTAL 61 1% 36

38 CASES TNM STAGE DISTRIBUTION - CMC-PINEVILLE TNM Stage NBR Cases Percent I II 38 9 III IV UNK 1 3 N/A TOTAL I II III IV UNK N/A TNM STAGE CASES STAGE BY SEX - CMC-PINEVILLE Age Range Male Female TOTALS I II III STAGE IV UNK N/A Male Female 37

39 STATE AND NATIONAL COMPARISONS - CMC-PINEVILLE PERCEN TAGE B r east Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC-Pineville NC Estimates US Estimates Type CMC NC US TOTAL 1 42,27 1,479,35 percent of total Breast 38% 13% 13% Lung 9% 16% 15% Prostate 4% 7% 13% Colorectal 8% 1% 1% Bladder 5% 4% 5% NH Lymphoma 4% 4% 4% Corpus Uteri 2% 2% 3% Melanoma 4% 5% 5% Leukemia 1% 3% 3% Cervis % 1% 1% All Others 25% 34% 29% 38

40 COUNTY DISTRIBUTION OF CANCER CASES - CMC-PINEVILLE 1. Mecklenburg Stanly Horry, SC 1 2. York, SC Burke 2 2. Marion, SC 1 3. Union Iredell Montgomery 1 4. Lancaster, SC Lincoln Rowan 1 5. Chester, SC Union, SC Sumter, SC 1 6. Gaston Alexander Transylvania 1 7. Cabarrus Buncombe Wake 1 8. Chesterfield, SC Caldwell 1 9. Rutherford Catawba 1 North Carolina 384 South Carolina 21 Out of State 7 Total NORTH CAROLINA SOUTH CAROLINA OTHER OUT OF STATE TOTAL

41 Major Site Report: CERVIX The cervix is the narrow portion of the uterus that opens at the top of the vagina. In the United States, cervical cancer is the eighth most common cancer in women. In 21, the American Cancer Society (ACS) has estimated that 12,2 cases will be diagnosed and 4,21 deaths will occur. Incidence rates have gradually decreased over past decades in Caucasian and African American women. The incidence of cervical cancer is greater worldwide than in North America. While the predominance of patients are Caucasian the actual risk is slightly higher for African American and Hispanic women (Figure 1). Prognosis is related to the stage of disease at diagnosis and to a lesser degree, the pathologic subtype. Staging has traditionally been defined by the International B. MCCALL, MD Federation of Gynecology and Obstetrics (IFGO). The American Joint Committee on Cancer (AJCC) recently published a new edition of the AJCC Cancer Staging Manual, which includes revisions to the staging for this disease. The majority of patients present with earlier stage disease (I and II). This breakdown for patients seen in The Carolinas HealthCare System (CHS) is seen in Figure 2. The age at presentation is included and mirrors the national averages (Figure 3). The prevalence of histological subtypes of cervical cancer correlates with the predominate cell type, squamous cells. The breakdown for CHS is seen in Figure 4. The Papanicolaou test or Pap smear, one of the most historic and effective screening test in oncology, is used to detect premalignant and malignant (cancerous) processes in the ectocervix. The latest in the various sophisticated classification systems for premalignant conditions are used by the pathology specialist at CHS. Malignant transformation appears almost categorically associated with Human Papillomavirus and encouraging reduction in the incidence of cancerous precursors with HPV vaccines have led to FDA approval and more widespread indications. While the overall five year survival in treated cervical cancer is about 72 percent, women with Stage I disease have an 8-9 percent survival and those with Stage II have a 5-65 percent five year survival. Only percent of patients with Stage III disease and fewer than 15 percent of those with Stage IV disease are alive after five years. The standard treatment modalities for cervical cancer include surgery, radiation therapy and chemotherapy. The majority of cervical cancers are treated non-surgically with radiation. This is usually with a combination of external beam therapy and internal treatment or brachytherapy. Multiple prospective randomized trials show an overall survival advantage to use of platin-based systemic chemotherapy given concurrently with radiation. Surgery and radiation are equally effective for early stage small volume disease. Potential benefits of surgery over radiation in this subset may be offset by the need for adjuvant radiation (+/- chemotherapy) if high risk features are found. Technological breakthroughs relating to more preferential delivery of external beam radiation (3-D and Intensity Modulated Radiotherapy), are improving the therapeutic ratio and leading to improved controls rates and reduced toxicities. The breakdown for treatment modality at CHS is similar to national averages (Figure 5). Improved education on the importance of screening, advanced systems for detecting and classifying precancerous conditions, effective HPV vaccines, sophisticated imaging and targeting of radiation matched with the synergistic sensitizing systemic agents, have contributed to the improved outcomes and reduced incidence of this malignancy. Carolinas HealthCare System will continue its uncompromising commitment to excellence in the individualized treatment of this disease through a comprehensive multi-modality approach. American Cancer Society: Cancer Prevention and Early Detection Facts and Figures 21 FDA Licenses New Vaccine for Prevention of Cervical Cancer. U.S. Food and Drug Administration

42 RACE/ETHNICITY OF CERVIX UTERI CANCER DIAGNOSED IN 2 TO 28 (FIGURE 1) White Black Hispanic API Native American Unknown Race Cases Percent White % Black % Hispanic % API % Native American 2.41% Other Unknown 3.61% TOTAL 489 1% STAGE OF CERVIX UTERI CANCER DIAGNOSED IN 2 TO 28 (FIGURE 2) CASES Stage Number Percentage 2.41% I % II % III % IV % UNK % TOTAL 489 1% 5 I II III IV V STAGE 41

43 CASES AGE GROUP OF CERVIX UTERI CANCER DIAGNOSED IN 2 TO 28 (FIGURE 3) Age Group Number Percentage % % % % % % % 9 and over 1.2% TOTAL 489 1% & over AGE RANGE PERCENTAGE HISTOLOGY OF CERVIX UTERI CANCER DIAGNOSED IN 2 TO 28 (FIGURE 4) Squamous Cell Carcinoma, NOS Keratinizing Squamous Cell Carcinoma, NOS Large Cell, Nonkeratinizing Squamous Cell Carcinoma Adenocarcinoma, NOS HISTOLOGY Adenosquamous Carcinoma Other Specified Types Histology Number Percentage Squamous Cell Carcinoma, NOS % Keratinizing Squamous Cell Carcinoma, NOS % Large Cell, Nonkeratinizing Squamous Cell Carcinoma % Adenocarcinoma, NOS % Adenosquamous Carcinoma % Other Specified Types % TOTAL 489 1% 42

44 FIRST COURSE TREATMENT OF CERVIX UTERI CANCER DIAGNOSED IN 2 TO 28 (FIGURE 5) PERCENTAGE First Course Treatment Number Percentage Surgery Only % Radiation Only % Surgery & Radiation % Radiation & Chemotherapy % Surgery, Radiation & Chemotherapy % 5 Other Specified Therapy % Surgery Only Radiation Only Surgery & Radiation Radiation & Chemotherapy Surgery, Radiation & Chemotherapy FIRST COURSE TREATMENT Other Specified Therapy No 1st Course Rx No 1st Course Rx % TOTAL 489 1% 43

45 Cummulative Survival Rate OBSERVED SURVIVAL FOR CASES DIAGNOSED IN 23 DATA FROM 183 FACILITIES (NATIONAL) (FIGURE 6) Chart Stage Total 168 I 368 II 1839 III 1655 IV 877 Cummulative Survival Rate Dx 1 year 2 years 3 years 4 years 5 years Years From Diagnosis OBSERVED SURVIVAL FOR CASES DIAGNOSED DATA FROM CMC NETWORK (FIGURE 7) Chart Stage Total 6 I 123 II 5 III 17 IV 11 Begin % 1 year 2 years 3 years 4 years 5 years Years From Diagnosis

46 Contact Us For more information on Blumenthal Cancer Center at CMC or to make patient referrals, please contact us at: or Learn More about our Cancer Network Partners CMC-Mercy CMC-Pineville CMC-University Other Resources American Cancer Society 8-ACS