Message from the President & CEO John Solheim, FACHE

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2 Message from the President & CEO John Solheim, FACHE Welcome to the 8 edition of the St. Peter s Hospital Cancer Program Annual Report. This report describes in detail the incidence of cancer and oncology services offered by St. Peter s Hospital in the past year. St. Peter s Hospital partners with its medical staff and healthcare professionals who work together as a team to provide the best diagnostic, treatment, and supportive services to Helena area residents diagnosed with cancer. Accredited by the Commission on Cancer of the American College of Surgeons, St. Peter s is proud to meet established national standards that ensure its cancer patients receive the best possible care. The Cancer Treatment Center at St. Peter s offers comprehensive services by Board-certified experienced physicians and a compassionate, professional staff. St. Peter s is continuing to fight cancer with the newest technology and now boasts higher than average national five-year survival rates for breast, prostate, and colorectal cancers. The Hospital is grateful to its many friends whose generous gifts have made improvements possible and enabled St. Peter s to provide state-of-the-art treatment. St. Peter s is pleased to provide leadership in improving the overall health of the Helena area community by providing exceptional cancer treatment.

3 Cancer Committee The Cancer Committee of St. Peter s was established in 1995 and is composed of members from all hospital services involved in the care of cancer patients. The committee meets quarterly to plan and assess all cancer-related activities at St. Peter s Hospital. The duties of the Cancer Committee are to provide leadership for the Cancer Program and evaluate the quality of cancer patient care and supervision of the Cancer Registry. The goals of St. Peter s Cancer Committee include: offering a comprehensive, integrated health care delivery system, improving the overall health status of the community, achieving and sustaining balanced financial performance of resources, promoting a culture of teamwork and excellence, being accountable to the communities we serve, continuing to improve the quality of care, and to deliver the most advanced treatment for our patients. 7-8 Cancer Committee Membership Robert Pfeffer, M.D. Radiation Oncology, Chair Thomas C. Weiner, M.D. Medical Oncology Natalie Gonzales, D.O. Surgery, Cancer Physician Liaison Ron Mow, M.D. Urology Dennis Palmer, M.D. Radiology Don Schultz, M.D. Pathology Mark Kreisberg, M.D. Hospitalists Maria Huntley, M.D. Ob/Gyn Karen Cody, MD Family Practice Jim Haley, M.D. VPMA Administration Amy Grassey, MBA Director Clinical Operations Jeanne Andre, CTR Cancer Registry Cancer Program Coordinator Mary Thomas, RN, OCN Cancer Treatment Center Jan Jahner, RN, CRNH Pain Management/Hospice Peggy Stebbins, APR Director, Public Relations & Marketing Gianluca Pisciarelli Quality Specialist Janis Ahlstrom, BSW Social Services Starla Blank, PharmD Pharmacy Clinical Coordinator Jennifer Colegrove, RD Nutrition Education Terri Stevens, LPN Cancer Treatment Center Karrie Fairbrother, BSN, RN, DNC Education Billie Mattson, RT, (R) (T) (CT) Radiation Therapist Laura Holien Cancer Data Specialist

4 Cancer Registry Jeanne Andre, CTR Cancer Program Coordinator The Cancer Registry is a data collecting system that is used to maintain and analyze clinical cancer information on all inpatients and outpatients diagnosed and/or treated for cancer at St. Peter s. The data is used for the purpose of research, education, and outcome measurements. St. Peter s Cancer Registry was established January 1, 1991 and is an essential component of an approved cancer program. There are currently over 5, cases entered into the registry. The registry is responsible, by law, for identifying and reporting all malignant and certain benign tumors to the Montana Central Tumor Registry. St. Peter s registry participates in submitting statistical data to the National Cancer Database and the Facility Information Profile System (FIPS) data-sharing project with the American Cancer Society. These NCDB studies include St. Peter s cancer database as a part of national statistics for incidence reporting and cancer research, which provides a comprehensive and comparative database of combined national data and St. Peter s registry data. In 7, a total of 339 cases were collected, with 318 (94%) analytic cases and 21 (6%) non-analytic cases. Analytic cases are the basis for the statistical reporting and analysis for the Registry. Quality assurance of registry data is accomplished by a random review of % of all abstracted data by physician members of the Cancer Committee. The software program automatically performs quality edit checks on all abstracted cases. Lifetime patient follow-up of all cancer patients is a primary goal of the registry. This process not only provides reminders to the physicians and patients to schedule regular examinations for continued medical supervision, but also provides data for clinical outcomes. Annual follow-up ensures early detection and treatment of a recurrence of their cancer or early diagnosis of a subsequent cancer. The registry continues to maintain a 98% follow-up rate on all patients known to be alive. Tumor Conference Tumor Conferences are held on the first and third Wednesday of each month to provide a multidisciplinary forum for discussion of current cancer cases. Physician members discuss the diagnosis, clinical staging, treatment options, and outcomes for each case to help determine the best possible treatment plans for the patient. Pathological and diagnostic imaging interpretations of each case are also presented. All physicians and professional employees involved in the care of cancer patients are invited to attend. St. Peter s Hospital, through an agreement with the University Washington School of Medicine, provides continuing education credits for physicians. Each conference is accredited for 1. hour CME credit. During 7, a total of 22 conferences were held with 59 cases presented, 98% of these cases were prospective, i.e. discussed at a time where diagnostic evaluation, treatment and follow-up care would be influenced. To schedule case presentations or for further information, please call Jeanne Andre at

5 Cancer Incidence 7 St. Peter's and National Comparisons St. Peter's 311 National 1,437,18 % of total % of total ORAL Tongue.9.7 Mouth.3.7 Pharynx.9.8 Other.1 DIGESTIVE Esophagus 1 1 Stomach Small Intestine.3.4 Colorectal.9.6 Liver / Biliary Pancreas Other Digestive.3 RESPIRATORY Larynx Lung and Bronchus Other Respiratory.3 BONE.2 CONNECTIVE TISSUE.7 SKIN - MELANOMA BREAST GENITAL 18.8 Cervix Uteri Corpus Uteri Ovary Other Female.4 Prostate Testis.6.5 Other Male.8 URINARY Bladder Kidney / Ureter EYE.2 BRAIN ENDOCRINE Thyroid Endocrine / Other.1 LEUKEMIA Lymphocytic Myeloid Other Leukemia.4 LYMPHOMA / OTHER BLOOD Hodgkin's.6 Non-Hodgkin's Other Blood.6 MULTIPLE MYELOMA ALL OTHER TOTALS % % Source: St. Peter's Hospital Cancer Registry data and CA A Cancer Journal for Clinicians

6 7 Analytic Cancer Cases by Sex and Stage St. Peter s Hospital STAGE PRIMARY SITE TOTAL MALE FEMALE I II III IV UNK ORAL Tongue Mouth Pharynx Other DIGESTIVE Esophagus Stomach Colon Rectum Liver/Biliary Pancreas RESPIRATORY Larynx Lung Other Respiratory BONE CONNECTIVE TISSUE SKIN Melanoma BREAST GENITAL Cervix Uteri Corpus Uteri Ovary Other Female Prostate Testis URINARY Bladder Kidney / Ureter EYE BRAIN / CNS ENDOCRINE Thyroid LEUKEMIA Myeloid Lymphocytic OTHER BLOOD / LYMPH Hodgkin s Non-Hodgkin s Myeloma 2 2 Other Blood 2 2 ALL OTHER TOTALS Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: St. Peter s Hospital Cancer Registry data

7 St. Peter s Hospital FIVE MOST FREQUENT SITES National Cancer Incidence 7 7 New Cases 311 Est. New Cases - 1,437,18 Breast 71 (22%) Lung 215, (15%) Lung 45 (14%) Prostate 186,3 (13%) Prostate 43 (14%) Breast 184,45 (13%) Colorectal 34 (11%) Colorectal 148,8 (%) Bladder 17 (5.5%) Bladder 68,8 (5%) Source: ACoS and SPH Cancer Registry data 45 Age at Diagnosis All Sites Number of Cases Age Male Female % Observed 5 Year Survival St. Peter's Five Major Sites Breast 9 Prostate 8 Bladder 7 Colorectal Survival Rate Lung Months from Diagnosis

8 Breast Cancer Natalie Gonzales, D.O. Breast cancer remains one of the three most commonly diagnosed types of cancer among women in 7. Nationwide an estimated 184,45 new cases will be diagnosed this year, with an estimated 75 new cases in the Helena service area. Twenty-two percent of all cancers diagnosed and treated at St. Peter s are breast cancer cases, while the rest of the country has a 12.8% incidence rate. Historically we have averaged 21% incidence compared to a national average of 14.5% incidence rate. The vast majority of our breast cancer cases are diagnosed in the early stage of the disease. Between 2 and 7, 7% were being diagnosed in stages I and II, and 96% in stages III. In 7 alone, 18% of the cases were stage or carcinoma in situ, 48% of the cases were stage I and 27% stage II. St. Peter s compares favorably with the national averages for these stages of disease. Age wise the majority of our breast cancer patient s tend to be slightly younger than the national average, primarily in the 5-59 age groups. Treatment for breast cancer varies according to medical circumstances and the patient s preferences, and may involve lumpectomy (local removal of the tumor) and removal of the lymph nodes under the arm; mastectomy (surgical removal of the whole breast) and lymph nodes; chemotherapy, radiation therapy and or hormonal therapy. Many times treatment will involve a combination of all of these therapies. Early stage breast cancer, stages I and II, are the group most likely to undergo a lumpectomy and women with more advanced stages of breast cancer, stages III and IV, are undergoing mastectomies almost twice as often than those with lumpectomies in these stages. The five year survival rate for St. Peter s shows that we have equal rates of survival for those in stage II, with that of the national average, but in those with stage III (who had more than twice as many mastectomies as lumpectomies) our survival rate was 8% when the national average was 56%. The 5-year relative survival for localized breast cancer has steadily increased since 199, and we can expect this trend to continue given the advancements that are being made for the diagnosis and treatment of breast cancer. In the past we used to think primarily in terms of cure rates for breast cancer, which meant that a patient had survived without a recurrence for at least 5 years. Now we think more in terms of survival of breast cancers. Many more women with advanced or recurrent breast cancers have much higher rates of survival, because we are thinking in terms of controlling the disease process, just like we control other diseases like diabetes and heart disease.

9 Age at Diagnosis 35 % Breast Cancer Percentage Age National St. Peter's Stage at Diagnosis - Breast Cancer 4 % Percentage 15 5 I II III IV Unk National St. Peter's Stage National St. Peter's Mastectomy and Lumpectomy Comparison Percent Mastectomy Lumpectomy National St. Peter's National St. Peter's

10 Surgical Treatment by Age St. Peter's Hospital Percent Age n=71 Mastectomy Lumpectomy / Partial Mastectomy % Surgical Treatment by Stage St. Peter's Hospital 7 25 Percent 15 5 Stage Stage I Stage II Stage III Stage IV n=71 Mastectomy Lumpectomy / Partial Mastectomy % Observed 5 Year Survival Breast Cancer By Stage Survival Rate Stage Stage I Stage II Stage III Stage IV National St. Peter's

11 Bladder Cancer The American Cancer Society reports an estimated 68,8 new cases of bladder cancer for 8, this includes 51,2 cases in men, and 17,58 cases in women. Overall, the incidence rate is almost three times greater in men than in women. Bladder cancers accounted for 7% of all newly diagnosed cases of cancer in men and 2.5% in women in the United States. Bladder cancer incidence at St. Peter s shows 8.7% of the newly diagnosed cancer cases in men and 2.9% in women. An estimated 14, deaths, or 2.5%, of all deaths are from bladder cancer in the United States. The most frequent presenting feature of bladder cancer is blood in the urine which occurs in 8% of the patients. This is usually associated with frequency of urination. Early detection can be diagnosed by examination of the bladder wall with a cystoscope. This is an instrument fitted with a lens and light that can be inserted into the urinary tract through the urethra. One of the greatest risk factors associated with bladder cancer is cigarette smoking, with smokers experiencing twice the risk as nonsmokers. Despite efforts to decrease smoking, there has been a steady increase in the incidence of this largely preventable cancer. Bladder cancer incidence at St. Peter s show 41% are current smokers, and 52% former smokers. The primary treatment for papillary bladder tumors that do not invade the bladder muscle is transurethral resection. This is used in over 89% of the cases at St. Peter s, with fewer patients requiring radical cystectomy (bladder removal) as the primary treatment. Despite complete tumor resection, an average of two-thirds of the patients will develop a recurrence within five years. At one time bladder cancer was considered resistant to chemotherapy but with increased use of combination chemotherapy there has been an increase in complete response and long-term disease free survival in patients with metastatic disease. Tobacco History 6% 1% 41% 52% Unk Present Former Never * Considered former smoker if patient quit 6 months prior to diagnosis

12 % Age and Sex at Diagnosis Bladder Cancer 25 Percent 15 5 n= Age Male Female Urothelialcellca-bladder cancer cells Stage AJCC Stage at Diagnosis Bladder Cancer I II III IV Unk % Percent of Total Cases Urothelialcellca-bladder cancer cells National St. Peter's Hospital Observed 5 Year Survival for Bladder Cancer % Survival Rate yr.5 yr 1. yr 1.5 yr 2. yr 2.5 yr 3. yr 3.5 yr 4. yr 4.5 yr 5. yr Years from Diagnosis National St. Peter's Urothelialcellca-bladder cancer cells

13 DEFINITION OF TERMS AJCC American Joint Commission on Cancer organized for cancer staging and end results reporting. Analytic Case Diagnosed and/or received the first course of treatment at St. Peter s Hospital. Non-Analytic Diagnosed and received all of the first course of treatment elsewhere prior to admission to St. Peter s for subsequent treatment; or a case diagnosed at autopsy. Incidence Newly occurring cancer cases during a given period of time. Stage of Disease The extent of disease determined at the time of initial work-up for the first course of treatment. In Situ Neoplasm which fulfills all microscopic criteria for malignancy except invasion. Local Neoplasm which appears entirely confined to the organ of origin. Regional Neoplasm which has spread by direct extension to immediately adjacent organs, tissues and/or has metastasized to regional lymph nodes. Distant - Neoplasm which has spread beyond adjacent organs or tissue by direct extension and/or has developed secondary metastatic tumors, has metastasized to distant lymph nodes, or has been determined to be systemic in origin. TNM Stage The extent of disease determined clinically or pathologically using standards proposed by the American Joint Commission on Cancer (AJCC) Staging System. TUMOR: Primary tumor size/extent of disease. NODE: Regional lymph node involvement. METASTASIS: Absence or presence of distant metastasis. References: CA A Journal for Clinicians;March/April 8 Published by the American Cancer Society, Inc. Atlanta, GA. OncoLog, Registry Software Berkeley Heights, N.J. NCDB, Commission on Cancer, AcoS Benchmark Survival Report

14 St. Peter's Hospital 2475 Broadway Helena, MT Published 9