CAROLINAS MEDICAL CENTER CANCER NETWORK

2 A N N U A L R E P O R T (USING 2 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

Cancer Committee Chairman s Report.........2 Cancer Liaison Physician s Report.............3 Quality Assurance Report....................4 Cancer Committee Membership..............6 Cancer Conferences.........................7 Leading Sites - 2 Estimate................9 Patient Navigators......................... 2 Tumor Registry Statistics - Network Cancer Data............................2 Age by Sex Distribution...................4 Race Distribution........................4 TNM Stage Distribution..................5 Stage by Sex............................5 State and National Comparison.............6 County Distribution......................7 Carolinas Medical Center Cancer Data............................8 Age by Sex Distribution...................2 Race Distribution........................2 TNM Stage Distribution..................2 Stage by Sex............................2 State and National Comparison.............22 County Distribution......................23 Carolinas Medical Center-University Cancer Data............................3 Age by Sex Distribution...................32 Race Distribution........................32 TNM Stage Distribution..................33 Stage by Sex............................33 State and National Comparison.............34 County Distribution......................35 Carolinas Medical Center-Pineville Cancer Data............................36 Age by Sex Distribution...................38 Race Distribution........................38 TNM Stage Distribution..................39 Stage by Sex............................39 State and National Comparison.............4 County Distribution......................4 Major Site Report: (Network Wide) Major Site Report........................42 Incidence of Lung Cancer in the US.........44 Age Distribution.........................45 Race Distribution........................46 Histologies.............................46 Stage Distribution........................46 Overall Survival.........................47 Contact Us...............................48 Carolinas Medical Center-Mercy Cancer Data............................24 Age by Sex Distribution...................26 Race Distribution........................26 TNM Stage Distribution..................27 Stage by Sex............................27 State and National Comparison.............28 County Distribution......................29

Cancer Committee Chairman s Report Carolinas Medical Center s (CMC) Blumenthal Cancer Center is at the forefront of the fight against cancer. Within the system s Charlotte metro facilities, Blumenthal Cancer Center continues to serve as the largest provider of cancer services. Meanwhile, the development and incorporation of Carolinas Medical Center-Mercy, Carolinas Medical Center-Pineville and Carolinas Medical Center-University within the cancer realm has increased the total number of new cancer cases accessioned through our sister facilities to nearly 4,8. 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 treat more patients and families in the Carolinas and beyond. We value your support and partnership in this important JEFFREY S. KNEISL, MD work. The American College of Surgeons requires all accredited cancer facilities to designate achievement goals in several domains each year. Accordingly, the Cancer Liaison Report defines some of our 2 achievements. Also included are CMC Cancer Committee 2 accomplishments and 22 goals. Featured domains include clinical, community outreach, quality improvement and cancer programming goals. During 2, Cancer Committee achieved four goals: Clinical: Developed and expanded patient navigator program Community Outreach: Implemented Patient Family Advisory Council Quality: Developed Q cancer network awareness survey of NCCN guidelines Programmatic: Unification of cancer registry operations among CHS facilities For 22, Cancer Committee established the following goals: Clinical: Transition post-treatment breast cancer survivors to a Breast Cancer Survivorship Clinic for follow-up care. Programmatic: Consultation to the fertility preservation program will be offered and/or referred to a minimum of 26 patients. 2 achievements were substantial and continue to demonstrate the dedication of our team. Our wonderful physicians, nurses and staff continuously strive to provide excellent care and service to cancer patients and families throughout the Carolinas and beyond. At Levine Cancer Institute, we are changing the course of cancer care. Respectfully submitted, Jeffrey S. Kneisl, MD, FACS Medical Director, Blumenthal Cancer Center 2

Cancer Liaison Physician s Report Once again, the cancer program at Carolinas Medical Center s Blumenthal Cancer Center received full approval from the Commission on Cancer (CoC) and, for the second time, the CoC Outstanding Achievement Award. These achievements recognize the contributions made possible by those dedicated to the care of our cancer patients, including physicians, nurses, administrators, registrars and other personnel. The cancer program at Carolinas Medical Center s Blumenthal Cancer Center continues to expand at an incredible pace. In 2, 2,695 accession cases were a full 7.6 percent more than the number in 29, continuing an increase over RICHARD L. WHITE, JR., MD many years. Accession cases do not include several hundred additional cancer cases seen in consultation for second opinions, or completing cancer care that may have been initiated elsewhere. As we move forward with Levine Cancer s Institute s network program, it is relevant to note that,85 additional cases were diagnosed at CMC-Pineville, CMC-Mercy and CMC-University. CMC Cancer Network accessioned 4,27 total cases, representing a remarkable expansion in cancer care within our region. Our mix of patients reflects national trends that one would expect with the most common diagnoses representing breast, lung and prostate cancers. Given our notable programs, a substantial number of patients with GYN malignancies, melanoma, kidney and brain cancers also have been treated. Continuing our strong presence in research, 422 of 3,695 patients were recruited to clinical trials. CMC stands in stark contrast to the national average of four percent for enrollment in clinical trials, continuing to accrue well in both industry and cooperative group trials. Oncology community outreach remains at a high level. Carolinas HealthCare System and Blumenthal Cancer Center were involved in 7 community events that enabled interaction with over 9, participants. In our continuing goal to develop stronger partnerships, many of these events were combined efforts with the American Cancer Society. At Carolinas HealthCare System, we are proud of our work as a network-accredited program and excited about our future in changing the course of cancer care across the Carolinas and beyond. Richard L. White, Jr., MD, FACS Cancer Liaison Physician Chief, Division of Surgical Oncology 3

Quality Assurance Report The quality assurance committee is charged with performance of two clinical practice guidelines studies, and two in-house reviews. The clinical practice guidelines studies are compared to a national benchmark, generally the National Cancer Center Network, to determine if recommendations made by that group have been followed in clinical practice within our network. In-house reviews evaluate specific areas of concern where quality of care has not yet been well assessed or can be improved. These studies often highlight accomplishments made by various hospital departments and their personnel. This year s presentations showcase several departments and physicians that excel in offering newer technology or methods of treatment, and it s implementation in a way that is practical and safe. MICHAEL HAAKE, MD Kris Gaston, MD, has been pivotal in building the bladder cancer treatment program in the Carolinas HealthCare System, reporting the incidence and mortality of this disease at his presentation for the QA Committee. He noted the U.S. Intergroup Study 8, demonstrating a 2 / 2 year survival benefit by offering combination chemotherapy with cystectomy, as opposed to cystectomy alone, for locally advanced bladder cancer. From 26 to early 28, 2 percent of patients in the network who had a cystectomy for locally advanced bladder cancer received perioperative chemotherapy. Subsequent to introduction of a multidisciplinary conference spearheaded by Dr. Gaston, numbers increased to 44 percent in 28 through 29. John Doty, MD, presented the first six months of endoscopic transbronchial ultrasound (EBUS) utilization at Carolinas Medical Center. He noted that in 29, 5 patients were offered this diagnostic modality. In 2, 36 patients underwent this procedure. On review of the first six months of EBUS utilization, Dr. Doty found that adequate sampling of tissue was obtained 84 percent of the time, and that the procedure was quite safe, with a 6 percent adverse effect rate. Adequate sampling and equivalent safety was obtainable with or without general anesthesia, leading him to believe that this technology could be used in situations where general anesthesia is not available, perhaps expanding the reach to other centers within the network. David Tait, MD, presented a review of the treatment of ovarian cancer patients from 28. 77 patients were discovered in the registry, and 49 percent were stage III. Adjuvant Platinum/Taxane chemotherapy, as recommended by the NCCN, was given in percent of the patients cases, and optimal cytoreduction was obtained in 87 percent of those. The Gynecologic Oncology Group noted that 7 percent of the patients in the study were optimally debulked, and CHS exceeded this benchmark. Jonathan Salo, MD, reported on our network experience of providing minimally invasive esophagectomy on select patients with esophageal cancer. He reported on 32 cases, noted no deaths and an average hospital stay of days. He pointed out that this effort, much like all cancer care at CHS, was credited to multiple disciplines including thoracic surgery, gastroenterology, nutrition services, the surgical critical care unit and the pathology department. Other studies included a review of patients treated with interferon at Carolinas Medical Center from 996 through 29, presented by Richard White, MD, and a review by Benjamin Calhoun, MD, on hormone receptor testing and HER-2/neu testing in breast cancer from 28 to 2. The percentage of patients 4

with receptor/her-2/neu positive and negative findings did not differ from what was expected and documented in the current literature. The Commission on Cancer also requests that the Quality Assurance Committee keep a list of improvements which were quite numerous this year including: The formation of a Family Advisory Council by Kevin Plate and the hiring of nurse navigators with the gynecologic oncology program, the genitourinary oncology program and the Blumenthal Cancer Center. In 2, Asim Amin, MD and others aided in the development of chemotherapy sets available for order online. In February 2, a new radiation oncology department at Morehead Medical Plaza II opened, with new Novalis and Trilogy stateof-the-art linear accelerators, and two small procedure rooms for outpatient brachytherapy delivery. This facility also made the leap to electronic medical records as its sole documentation method. Another final improvement that merits a round of applause is the Commission on Cancer award presented in August. This was a three-year accreditation with commendation award. That was the culmination of efforts by the cancer committee members and many others. In October 2, the formation of Levine Cancer Institute was announced. The Quality Assurance Committee looks forward to continuing its service under the banner of LCI, and welcomes suggestions for areas of study to facilitate the continued improvement in the care of cancer patients. Quality Assurance Chairmen Michael Haake, MD Stuart Salmon, MD Sridhar Pal, MD Reza Nazemzadeh, MD Assurance Director Quality Assurance Chair Quality Assurance Chair Quality Assurance Chair CHS Oncology Quality CMC-Pineville CMC-University CMC-Mercy 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 - CMC-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 - CMC-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 Liaison Physician Phyllis Wingate-Jones Warden Woodard, MD 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 General Tumor Board (Teleconferenced) GI Tumor Planning Conference Gynecology Tumor Board (Teleconferenced) Head and Neck Conference 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 Consortium (AHEC). Dr. Jonathan Salo 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, South Carolina. We continue to use web-based video conferencing for the Breast Tumor Board and the Head and Neck Conference. This technology allows for interactive conferencing with users over the internet and archiving of presentations for later review. Dr. Salo updated the Cancer Committee throughout 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 video conferencing for cancer conferences, both within Carolinas Medical Centers, Carolinas Physicians Network (CPN) and with area physicians. 7

Cancer Conferences CMC Network SITE 2 Abdomen 2 Adh Adrenal 3 Angiosarcoma Anus/anal 2 Appendix Atypical spitz Bladder 3 Bones/soft tissue 533 Breast 8 Carcinoid 9 Cardiac mets Cecum Cervix 3 Chest wall mass 2 Cholangiocarcinoma Chronic atelectasis Colon 24 Colorectal 5 Didactic 6 Endometrium 2 Esophagus 22 Fallopian tube Gallbladder 6 Ge junction 2 Gi bleed Gi stromal Gist 9 Hcc 4 Head & neck 7 Hodgkin's 7 Inguinal mass Ipmn 2 Ivc sarcoma Kidney 246 Langerhans histiocytosis Larynx 4 Leiomyosarcoma Lip 2 Liver 9 SITE 2 Lung 52 Lymph 7 Mandible Malignant myoepitheluioma Maxillary sinus Mds Mediastinal 4 Medulloblastoma Metastatic choriocarcinoma Mouth Multiple myeloma Nasal cavity & ear 2 Neck 4 Neuroendocrine Nasopharynx Nsclc Omentum Oropharynx Ovary 5 Pancreas 4 Paraganglioma Parathyroid Parotid 5 SITE 2 Pelvic 6 Periampullary Phyllodes tumor 5 Porocarcinoma Positive brca 2 Presacral carcinoma Prostate Rectum 2 Renal cell 57 Retroperitoneum 4 Scalp Scrotum Sigmoid colon 3 Sinus 2 Skin 2 Supraglottic 2 Testis Thyroid 3 Tongue 4 Tonsil 3 Unknown primary 4 Urothelial Vascular malformation Totals,64 8

Leading Sites of New Cases and Deaths 2 Estimates Estimated New Cases* Estimated Deaths Male Female Male Female Prostate Breast 27,73 (28%) 27,9 (28%) Lung & Bronchus Lung & Bronchus 6,75 (5%) 5,77 (4%) Colon & Rectum Colon & Rectum 72,9 (9%) 7,48 (%) Urinary Bladder Uterine Corpus 52,76 (7%) 43,47 (6%) Melanoma of the Skin Thyroid 38,87 (5%) 33,93 (5%) Non-Hodgkin s Non-Hodgkin Lymphoma Lymphoma 35,38 (4%) 3,6 (4%) Kidney & Renal Pelvis Melanoma of the Skin 35,37 (4%) 29,26 (4%) Oral Cavity & Pharynx Kidney & Renal Pelvis 25,42 (3%) 22,87 (3%) Leukemia Ovary 24,69 (3%) 2,88 (3%) Pancreas Pancreas 2,37 (3%) 2,77 (3%) All Sites All Sites 739,94 (%) 739,94 (%) Lung & Bronchus Lung & Bronchus 86,22 (29%) 7,8 (26%) Prostate Breast 32,5 (%) 39,84 (5%) Colon & Rectum Colon & Rectum 26,58 (9%) 24,79 (9%) Pancreas Pancreas 8,77 (6%) 8,3 (7%) Liver & Intrahepatic Bile Duct Ovary 2,72 (4%) 3,85 (5%)) Leukemia Non-Hodgkin s 2,66 (4%) Lymphoma 9,5 (4%) Esophagus Leukemia,65 (4%) 9,8 (3%) Non-Hodgkin s Lymphoma Uterine Corpus,7 (4%) 7,95 (3%) Urinary bladder Liver &,4 (3%) Intrahepatic Bile Duct 6,9 (2%) Kidney & Renal Pelvis Brain & Nervous System 8,2 (3%) 5,72 (2%) All Sites All Sites 299,2 (%) 27,29 (%) 2, American Cancer Society, Inc. Surveillance and Health Policy Research * *Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder. 9

Patient Navigators The nurse navigator is a registered nurse dedicated to advocating for cancer patients and their families and making sure they receive the support and knowledge to successfully navigate through the healthcare system. The goal of the navigator is to expedite entry of the patient into the system and to eliminate barriers that will interfere with treatment. The Navigator: makes the delivery of care more efficient works with patients and families to find resources and support provides expert knowledge to help patients and families understand the disease, current treatment options and the availability of clinical trials guides patients through the cancer care continuum from the time of diagnosis through treatment and survivorship offers emotional support and guidance to patients and families helps with rapid scheduling for assessments, tests, surgery and therapy advocates on patients behalf to enhance communication with healthcare staff and providers facilitates entry into clinical trials as appropriate Hospitals around the country have added patient navigation services. The Commission on Cancer has issued new standards that will require cancer centers to offer patient navigation by 25 to meet accreditation. The nurse navigator is the one constant presence among the many who are involved in the care of the patient. PATIENT NAVIGATOR TUMOR SITE # OF NUMBER FACILITY NAME FOCUS PATIENT CONTACTS CMC Susan Postell Breast 6 2 CMC Grace Sauzier Breast 5 3 CMC Darcy Doege Colorectal Started Fall 2 4 CMC Lisbeth Knapp Immunotherapy 2 5 CMC Nichole Filyaw Gyn 4 6 CMC Cassandra Horsley Lung 4 7 CMC Jane Daniels GU 5 8 CMC Melisa Wheeler ACS (All Tumor Sites) 6+

The Patient Resource Navigator program is a collaborative program between the American Cancer Society and Levine Cancer Institute. This community-based partnership allows outreach to those most in need during the cancer experience. In addition to following up on previously established patients, the patient resource navigator met with 5 new patients and families last year and provided 2,39 service requests. Each patient/caregiver met with the resources navigator an average of 6.6 times throughout the year and 63 percent were uninsured or underinsured. Patients participated in several of the programs offered by the American Cancer Society which resulted in $3,95 in transportation assistance, $7 in medication assistance, 69 Road to Recovery Rides, two nights at the Hope Lodge and 3 gift items. Patients were also guided to numerous hospital-based and community programs, assisted with applying for national grants and connected to insurance/financial resources such as Medicaid/social security disability.

2 Tumor Registry Statistics - Network REVIEW OF ANALYTIC ACCESSIONS CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A All Sites 4,27 3,935 336,873 2,398 328,9 88 523 57 263 589 Oral Cavity 2 3 9 85 27 6 6 8 22 36 9 5 Lip Tongue 45 39 6 29 6 4 6 8 8 5 3 Oropharynx 6 4 2 6 2 2 Hypopharynx 2 2 2 Other 58 57 47 2 8 9 3 8 4 4 Digestive System 652 598 54 359 293 25 38 58 8 39 6 4 Esophagus 34 27 7 23 5 5 2 Stomach 54 52 2 33 2 2 8 5 3 5 Colon 49 33 6 6 88 4 22 36 33 33 Rectum 85 74 42 43 6 29 8 Anus/Anal Canal 6 4 2 6 2 3 3 4 3 Liver 2 2 9 94 27 4 26 9 7 2 7 Pancreas 32 26 6 77 55 56 2 45 8 Other 6 6 23 38 9 9 8 5 Respiratory System 468 434 34 265 23 4 2 4 9 96 25 Nasal/Sinus 7 7 4 3 2 5 Larynx 3 27 4 26 5 4 8 2 4 7 5 Lung/Bronchus 426 396 3 232 94 9 38 86 88 9 4 Other 4 4 3 Blood & Bone Marrow 73 7 56 97 76 73 Leukemia 3 92 38 72 58 3 Multiple Myeloma 43 25 8 43 Other 2 8 4 2 Bone 24 23 9 5 8 6 4 2 3 Connect/Soft Tissue 6 59 2 33 28 3 2 5 3 7 3 Skin 275 239 36 6 5 46 22 39 29 4 5 Melanoma 255 22 34 5 4 46 8 34 29 4 3 Other 2 8 2 9 4 5 4 7 2

CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A Breast 795 779 6 5 79 5 296 28 57 29 43 2 Female Genital 48 47 48 3 26 26 77 4 9 9 Cervis Uteri 59 59 59 3 7 4 5 3 Corpus Uteri 96 94 2 96 36 9 7 22 3 9 Ovary 8 3 5 8 3 8 38 2 8 Vulva 44 4 4 44 3 7 2 2 Other 2 7 Male Genital 44 334 7 44 3 86 28 44 9 33 Prostate 384 34 7 384 76 24 42 9 33 Testis 5 5 5 3 2 Other 5 5 5 3 Urinary System 283 27 3 92 9 63 3 27 33 27 3 Bladder 4 29 2 8 33 6 29 6 7 7 22 Kidney/Renal 36 35 8 56 2 7 3 9 24 4 3 Other 6 6 4 2 2 Brain & CNS 29 24 5 89 3 29 Brain (Benign) 2 9 8 2 2 Brain (Malignant) 99 99 5 48 99 Other 96 4 3 7 Endocrine 29 26 3 46 83 5 7 9 52 Thyroid 73 72 8 55 49 7 9 8 Other 56 54 2 28 28 3 52 Lymphatic System 72 48 24 9 8 53 27 26 44 2 2 Hodgkin s Disease 29 25 4 8 4 6 7 Non-Hodgkin s 43 23 2 73 7 49 6 2 37 9 2 Unknown Primary 7 69 34 36 69 Other/Ill-Defined 6 5 4 2 8 2 2 4 3

AGE DISTRIBUTION - NETWORK 7 6 5 4 3 2-9 - 9 2-29 3-39 4-49 5-59 6-69 7-79 8-89 9-99 Age Range Male Female - 9 27 25-9 2 2 2-29 33 53 3-39 7 56 4-49 9 37 5-59 442 54 6-69 59 637 7-79 335 4 8-89 49 73 9-99 6 22 TOTALS,874 2,397 AGE RANGE Male Female RACE DISTRIBUTION - NETWORK White Black Other Race Cases Percent White 3,99 73% Black 9 2% Other 272 6% TOTAL 4,27 % 4

CASES TNM STAGE DISTRIBUTION - NETWORK 2 9 8 88 6 523 4 328 2 57 597 263 TNM Stage NBR Cases Percent 328 8% I,9 28% II 88 9% III 523 2% IV 57 3% UNK 263 6% N/A 589 4% TOTAL 4,27 % I II III IV UNK N/A TNM STAGE CASES STAGE BY SEX - NETWORK 8 6 4 Stage Male Female 8 22 I 387 83 II 48 4 III 238 284 IV 3 26 UNK 43 2 N/A 279 3 TOTALS,873 2,398 2 I II III STAGE IV UNK N/A Male Female 5

STATE AND NATIONAL COMPARISONS - NETWORK 4 35 3 25 PERCENTAGE 2 5 5 Breast Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC Network NC Estimates U.S. Estimates Type CMC NC US TOTAL 4,27 45,2 5,529,56 percent of total Breast 9% 4% 4% Lung % 7% 5% Prostate 9% 5% 4% Colorectal 5% 9% 9% Bladder 3% 4% 5% NH Lymphoma 3% 4% 4% Uterine 5% 3% 3% Melanoma 6% 5% 4% Leukemia 6% 3% 3% Cervix 2% % 8% All Others 29% 28% 2% 6

COUNTY DISTRIBUTION OF CANCER CASES - NETWORK. Mecklenburg 2,69 2. Anson 39 3. Brunswick 5 4. Alexander 5 5. Alleghany 6. Ashe 7. Avery 7 8. Barnwell, SC 9. Buncombe 5. Cherokee 7. Burke 34 2. Chester, SC 36 3. Cabarrus 36 4. Chesterfield, SC 8 5. Caldwell 23 6. Colleton, SC 7. Darlington, SC 4 8. Catawba 73 9. Fairfield, SC 3 2. Florence, SC 2. Cleveland 3 22. Greenville, SC 7 23. Columbus 24. Craven 25. Cumberland 2 26. Horry, SC 7 27. Kershaw, SC 2 28. Davidson 29. Lancaster, SC 3 3. Davie 3. Lexington, SC 3 32. Forsyth 6 33. Marion, SC 34. Franklin 35. Gaston 235 36. Newberry, SC 37. Richland, SC 4 38. Guilford 2 39. Spartanburg, SC 9 4. Haywood 3 4. Union, SC 2 42. Henderson 5 43. York, SC 46 44. Iredell 87 45. Jackson 4 46. Lincoln 7 47. Macon 48. Madison 49. Montgomery 5 5. Onslow 5. Orange 52. Pasquotank 53. Polk 4 54. Richmond 7 55. Robeson 3 56. Rockingham 57. Rowan 43 58. Rutherford 45 59. Scotland 3 6. Stanly 4 6. Stokes 62. Surry 63. Transylvania 2 64. Union 252 65. Wake 2 66. Warren 67. Watauga 68. Wilkes 69. Yadkin 7. Yancy 5 6 62 6 56 67 68 7 69 32 38 5 7 5 6 4 2 48 7 23 5 44 28 65 8 87 9 34 57 2 4 73 3 43 5 58 46 7 45 2 3 45 42 53 35 6 49 3 36 47 5 63 5 4 235 4 5 2,69 7 2 25 43 64 22 39 2 46 252 7 9 39 59 4 2 29 4 3 55 2 36 3 8 3 9 36 27 3 7 2 4 23 33 2 37 3 4 26 7 3 3 34 54 7 66 3 5 5 24 52 8 6 NORTH CAROLINA.............. 3536 SOUTH CAROLINA................664 OTHER/OUT OF STATE.............7 TOTAL.......................427 7

2 Tumor Registry Statistics - CMC REVIEW OF ANALYTIC ACCESSIONS CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A All Sites 3,695 3,363 332,574 2,2 267,36 693 454 496 2 539 Oral Cavity 3 95 8 79 24 5 6 5 2 36 6 5 Lip Tongue 42 37 5 26 6 4 5 7 8 5 2 Oropharynx 6 4 2 6 2 2 Hypopharynx 2 2 2 Other 52 5 44 8 9 7 8 2 4 Digestive System 536 487 49 32 26 2 4 4 94 26 4 Esophagus 35 26 9 26 9 5 7 2 Stomach 47 45 2 3 7 2 5 4 2 4 Colon 87 4 49 52 2 4 23 2 25 6 Rectum 48 42 6 24 24 3 4 6 8 5 Anus/Anal Canal 9 2 4 7 2 3 2 2 Liver 3 8 87 24 39 26 6 3 6 Pancreas 32 25 7 79 53 55 3 47 7 Other 5 5 2 3 7 9 6 5 4 Respiratory System 393 35 42 23 63 4 83 4 7 62 22 Nasal/Sinus 7 7 4 3 5 Larynx 32 27 5 26 6 4 7 2 4 8 5 2 Lung/Bronchus 35 34 37 98 53 75 37 67 52 6 4 Other 3 3 2 Blood & Bone Marrow 5 4 47 84 67 5 Leukemia 2 82 3 62 5 2 Multiple Myeloma 28 2 7 5 3 28 Other 7 4 Bone 24 23 9 5 8 6 4 2 3 Connect/Soft Tissue 62 59 3 34 28 3 2 5 3 8 3 Skin 249 22 37 47 2 45 6 34 27 2 6 9 Melanoma 232 97 35 38 94 45 2 3 27 2 2 3 Other 7 5 2 9 8 4 3 4 6 8

CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A Breast 7 68 2 4 697 42 264 88 5 22 34 Female Genital 427 46 427 3 29 3 82 37 8 2 Cervis Uteri 65 65 65 33 9 5 5 3 Corpus Uteri 98 95 3 98 37 7 2 3 Ovary 6 5 6 29 7 4 8 Vulva 44 4 3 44 29 8 2 2 Other 4 4 4 2 2 8 Male Genital 34 25 64 34 65 67 35 6 29 Prostate 3 237 64 3 58 64 34 6 29 Testis 7 2 Other 3 3 3 Urinary System 84 72 2 6 68 2 75 2 2 32 3 3 Bladder 6 52 8 46 4 8 6 7 5 5 9 Kidney/Renal 9 5 4 67 52 2 59 3 4 25 3 3 Other 5 5 3 2 2 Brain & CNS 2 26 5 87 24 2 Brain (Benign) 8 7 7 8 Brain (Malignant) 3 3 53 5 3 Other 9 86 4 27 63 9 Endocrine 2 8 3 43 78 49 7 8 46 Thyroid 7 69 2 7 54 48 7 8 8 Other 5 49 26 24 3 46 Lymphatic System 45 8 27 75 7 44 24 23 33 9 2 Hodgkin s Disease 26 22 4 5 3 6 5 Non-Hodgkin s 9 96 23 6 59 4 3 7 28 8 2 Unknown Primary 58 57 28 3 58 Other/Ill-Defined 6 5 4 2 8 2 2 4 9

AGE DISTRIBUTION - CMC 6 5 4 3 2-9 - 9 2-29 3-39 4-49 5-59 6-69 7-79 8-89 9-99 Age Range Male Female - 9 26 24-9 2 8 2-29 3 53 3-39 64 45 4-49 68 347 5-59 394 498 6-69 478 57 7-79 274 324 8-89 9 3 9-99 TOTALS,574 2,2 AGE RANGE Male Female RACE DISTRIBUTION - CMC White Black Other Race Cases Percent White 27 73% Black 755 2% Other 23 7% TOTAL 3,695 % 2

TNM STAGE DISTRIBUTION - CMC CASES 2 8 6 4 2 267 36 693 454 496 2 539 TNM Stage NBR Cases Percent 267 7% I 36 28% II 693 9% III 454 2% IV 496 3% UNK 2 6% N/A 539 5% TOTAL 3,695 % I II III IV UNK N/A TNM STAGE CASES STAGE BY SEX - CMC 8 7 6 5 4 3 Stage Male Female 7 97 I 38 728 II 343 35 III 2 253 IV 282 24 UNK 3 97 N/A 257 282 TOTALS,574 2,2 2 I II III STAGE IV UNK N/A Male Female 2

STATE AND NATIONAL COMPARISONS - CMC 4 35 3 25 PERCENTAGE 2 5 5 Breast Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC Main NC Estimates U.S. Estimates Type CMC NC US TOTAL 3,695 45,2 5,529,56 percent of total Breast 9% 4% 4% Lung 9% 7% 5% Prostate 8% 5% 4% Colorectal 4% 9% 9% Bladder 2% 4% 5% NH Lymphoma 3% 4% 4% Uterine 5% 3% 3% Melanoma 6% 5% 4% Leukemia 3% 3% 3% Cervix 2% % 8% All Others 39% 28% 2% 22

COUNTY DISTRIBUTION OF CANCER CASES - CMC. Alamance 2. Alexander 5 3. Alleghany 4. Anson 44 5. Ashe 8 6. Avery 7 7. Barnwell, SC 8. Bladen 9. Brunswick 5. Buncombe 5. Cherokee, SC 6 2. Burke 36 3. Chester, SC 3 4. Cabarrus 24 5. Chesterfield, SC 9 6. Caldwell 23 7. Colleton, SC 8. Darlington, SC 3 9. Catawba 68 2. Fairfield, SC 3 2. Florence, SC 22. Cleveland 3 23. Greenville, SC 5 24. Columbus 25. Craven 26. Cumberland 2 27. Horry, SC 6 28. Kershaw, SC 2 29. Lancaster, SC 88 3. Lexington, SC 3 3. Forsyth 5 32. Marion, SC 33. Franklin 34. Gaston 27 35. Richland, SC 4 36. Guilford 2 37. Spartanburg, SC 9 38. Haywood 3 39. Union, SC 2 4. Henderson 5 4. York, SC 336 42. Iredell 8 43. Jackson 4 44. Lincoln 8 45. McDowell 46. Macon 47. Madison 48. Mecklenburg,78 49. Montgomery 9 5. Onslow 5. Orange 52. Pasquotank 53. Polk 4 54. Richmond 5 55. Robeson 3 56. Rockingham 57. Rowan 42 58. Rutherford 45 59. Scotland 3 6. Stanly 56 6. Stokes 62. Surry 63. Transylvania 64. Union 24 65. Wake 2 66. Warren 67. Watauga 68. Wilkes 69. Yadkin 7. Yancey 46 43 5 38 3 5 3 8 62 6 67 68 6 69 3 6 5 47 7 7 2 23 5 42 45 2 36 9 8 57 68 5 42 58 44 8 45 22 4 4 53 34 48 6 63 3 24 5 27,78 56 4 4 64 6 336 24 37 9 39 2 3 3 29 88 4 44 5 9 49 9 56 36 2 54 5 59 3 5 55 3 65 2 26 2 8 66 33 5 25 52 9 28 8 3 2 3 32 35 2 3 4 3 27 6 24 9 5 7 7 NORTH CAROLINA.............. 32 SOUTH CAROLINA............... 52 OTHER/OUT OF STATE............. 62 TOTAL.......................3695 23

2 Tumor Registry Statistics - CMC-Mercy REVIEW OF ANALYTIC ACCESSIONS CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A All Sites 228 28 2 23 5 6 33 36 49 2 7 Oral Cavity 4 2 2 3 2 Lip Tongue 4 2 2 3 2 Oropharynx Hypopharynx OTHER Digestive System 79 72 7 36 43 3 25 4 6 9 2 Esophagus 3 2 2 2 Stomach 6 5 2 4 3 Colon 9 9 6 3 5 5 5 3 Rectum 37 33 4 2 7 2 6 7 6 5 Anus/Anal Canal 4 4 2 2 2 Liver 5 4 3 2 2 Pancreas 2 2 2 Other 3 3 2 2 Respiratory System 69 65 4 37 32 2 3 3 3 Nasal/Sinus Larynx Lung/Bronchus 68 64 4 36 32 2 3 3 3 Other Blood & Bone Marrow 4 4 3 4 Leukemia 3 3 3 3 Multiple Myeloma Other Bone Connect/Soft Tissue 3 3 2 Skin Melanoma Other 24

CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A Breast 7 6 7 4 Female Genital 5 5 5 2 2 Cervis Uteri Corpus Uteri 3 3 3 2 Ovary Vulva Other Male Genital 9 7 2 9 3 2 3 Prostate 9 7 2 9 3 2 3 Testis Other Urinary System 29 26 3 24 5 8 5 6 Bladder 23 2 3 9 4 7 6 4 6 Kidney/Renal 5 5 4 4 Other Brain & CNS 3 3 2 3 Brain (Benign) Brain (Malignant) Other 2 2 2 2 Endocrine 3 3 2 2 Thyroid Other 2 2 2 2 Lymphatic System 7 7 5 2 4 2 Hodgkin s Disease Non-Hodgkin s 6 6 4 2 4 2 Unknown Primary 6 5 3 3 5 Other/Ill-Defined 25

5 4 3 2 AGE DISTRIBUTION - CMC-MERCY Age Range Male Female 2-29 2 3-39 3 2 4-49 2 5-59 8 8 6-69 44 3 7-79 27 27 8-89 8 2 9-99 3 TOTALS 23 5 2-29 3-39 4-49 5-59 6-69 7-79 8-89 9-99 AGE RANGE Male Female RACE DISTRIBUTION - CMC-MERCY White Black Other Race Cases Percent White 43 63% Black 76 33% Other 9 4% TOTAL 228 % 26

CASES TNM STAGE DISTRIBUTION - CMC-MERCY 8 7 6 6 5 492 4 3 33 36 2 4 7 I II III IV UNK N/A TNM STAGE TNM Stage NBR Cases Percent 5% I 6 27% II 33 4% III 36 6% IV 49 2% UNK 2 9% N/A 7 7% TOTAL 228 % CASES STAGE BY SEX - CMC-MERCY 35 3 25 2 5 Stage Male Female 7 4 I 33 28 II 5 8 III 8 8 IV 27 22 UNK 6 5 N/A 7 TOTALS 23 5 5 I II III STAGE IV UNK N/A Male Female 27

STATE AND NATIONAL COMPARISONS - CMC-MERCY 4 35 3 25 PERCENTAGE 2 5 5 Breast Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC-Mercy NC Estimates U.S. Estimates Type CMC NC US TOTAL 228 45,2 5,529,56 percent of total Breast 3% 4% 4% Lung 3% 7% 5% Prostate 4% 5% 4% Colorectal 25% 9% 9% Bladder % 4% 5% NH Lymphoma 3% 4% 4% Uterine % 3% 3% Melanoma % 5% 4% Leukemia % 3% 3% Cervix % % 8% All Others 22% 28% 2% 28

COUNTY DISTRIBUTION OF CANCER CASES - CMC-MERCY. Anson 3 6. Cleveland 2. Gaston 2. Chester, SC 7. Greenville, SC 2. York, SC 2 3. Cabarrus 3 8. Horry, SC 3. Iredell 2 4. Chesterfield, SC 5 9. Davidson 4. Lincoln 8 5. Catawba 2. Lancaster, SC 3 5. Mecklenburg 4 6. Rowan 2 7. Stanly 5 8. Union 5 7 6 2 5 2 4 8 2 2 2 3 2 5 4 3 6 2 3 3 8 5 9 7 5 3 4 5 8 NORTH CAROLINA............... 94 SOUTH CAROLINA................ 32 OTHER/OUT OF STATE.............. 2 TOTAL........................228 29

2 Tumor Registry Statistics - CMC-University REVIEW OF ANALYTIC ACCESSIONS CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A All Sites 327 35 22 53 74 9 77 92 42 53 6 28 Oral Cavity 6 5 4 2 2 Lip Tongue 2 2 2 Oropharynx Hypopharynx Other 4 3 2 2 Digestive System 54 49 5 23 3 7 8 9 7 2 Esophagus 3 3 3 Stomach 4 3 3 2 Colon 7 6 6 2 4 8 Rectum 9 7 2 3 6 3 2 3 Anus/Anal Canal Liver 6 6 4 2 2 3 Pancreas 6 5 5 2 2 Other 9 9 3 6 3 2 2 Respiratory System 39 37 2 23 6 4 3 4 7 Nasal/Sinus 2 2 Larynx Lung/Bronchus 36 34 2 2 5 2 3 4 7 Other Blood & Bone Marrow 5 5 4 6 Leukemia 7 3 4 3 4 7 Multiple Myeloma 3 2 2 3 Other Bone Connect/Soft Tissue Skin 4 2 2 3 2 Melanoma 3 2 2 2 Other 3

CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A Breast 85 85 84 6 28 34 6 7 4 Female Genital 8 2 Cervis Uteri Corpus Uteri 5 5 5 5 Ovary 4 4 4 2 Vulva Other Male Genital 67 63 4 67 3 42 6 3 2 Prostate 64 6 4 64 2 42 5 3 2 Testis 2 2 2 Other Urinary System 26 26 9 7 9 2 2 2 Bladder 8 8 3 5 3 2 2 Kidney/Renal 8 8 6 2 6 2 Other Brain & CNS 4 3 3 4 Brain (Benign) Brain (Malignant) Other 3 2 3 3 Endocrine 3 2 3 3 Thyroid Other 3 2 3 3 Lymphatic System 9 5 5 2 2 4 Hodgkin s Disease Non-Hodgkin s 9 8 4 5 2 4 Unknown Primary 7 7 5 2 7 Other/Ill-Defined 3

8 7 6 5 4 3 2 AGE DISTRIBUTION - CMC-UNIVERSITY Age Range Male Female 2-29 2 3-39 2 5 4-49 3 25 5-59 35 47 6-69 72 4 7-79 22 3 8-89 6 4 9-99 - 9 TOTALS 53 74 2-29 3-39 4-49 5-59 6-69 7-79 8-89 9-99 - 9 - AGE RANGE Male Female RACE DISTRIBUTION - CMC-UNIVERSITY White Black Other Race Cases Percent White 9 58% Black 34% Other 26 8% TOTAL 327 % 32

TNM STAGE DISTRIBUTION - CMC-UNIVERSITY CASES 8 6 4 2 9 77 92 42 53 28 28 TNM Stage NBR Cases Percent 9 6% I 77 24% II 92 28% III 42 3% IV 53 6% UNK 6 5% N/A 28 9% TOTAL 327 % I II III IV UNK N/A TNM STAGE CASES STAGE BY SEX - CMC-UNIVERSITY 5 4 3 2 Stage Male Female 9 I 3 46 II 49 43 III 25 7 IV 24 29 UNK 5 N/A 8 TOTALS 53 74 I II III STAGE IV UNK N/A Male Female 33

STATE AND NATIONAL COMPARISONS - CMC-UNIVERSITY 4 35 3 25 PERCENTAGE 2 5 5 Breast Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC-University NC Estimates U.S. Estimates Type CMC NC US TOTAL 327 45,2 5,529,56 percent of total Breast 26% 4% 4% Lung % 7% 5% Prostate 2% 5% 4% Colorectal 8% 9% 9% Bladder 6% 4% 5% NH Lymphoma 3% 4% 4% Uterine 2% 3% 3% Melanoma % 5% 4% Leukemia 3% 3% 3% Cervix % % 8% All Others 9% 28% 2% 34

COUNTY DISTRIBUTION OF CANCER CASES - CMC-UNIVERSITY. Anson 2 6. Cleveland. York, SC 2 2. Beaufort, SC 7. Greenville, SC 2. Iredell 8 3. Chester, SC 8. Davie 3. Lincoln 9 4. Cabarrus 4 9. Forsyth 4. Mecklenburg 23 5. Darlington, SC. Gaston 8 5. Montgomery 6. Richmond 2 7. Rowan 5 8. Stanly 4 9. Union 5 7 6 3 9 8 2 2 8 4 23 8 7 5 4 4 9 8 4 5 9 5 2 6 2 5 3 5 NORTH CAROLINA............... 39 SOUTH CAROLINA................. 6 OTHER/OUT OF STATE.............. 2 2 TOTAL........................327 35

2 Tumor Registry Statistics - CMC-Pineville REVIEW OF ANALYTIC ACCESSIONS CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A All Sites 63 6 3 25 45 66 24 32 76 65 33 54 Oral Cavity 6 6 2 4 2 4 6 2 Lip Tongue 4 4 3 Oropharynx Hypopharynx Other 2 2 9 3 3 5 Digestive System 7 62 8 32 38 4 5 5 9 9 8 Esophagus 5 5 3 2 2 3 Stomach 3 3 3 Colon 3 26 4 2 2 4 8 8 4 4 Rectum 2 8 4 6 6 2 6 2 Anus/Anal Canal 2 2 2 Liver 3 3 3 Pancreas 9 9 5 4 6 2 Other 6 6 2 4 2 3 Respiratory System 47 43 4 26 2 5 4 2 24 2 Nasal/Sinus Larynx Lung/Bronchus47 43 4 26 2 5 4 2 24 2 Other Blood & Bone Marrow 7 7 2 5 7 Leukemia 5 6 7 4 Multiple Myeloma 5 5 4 5 Other Bone Connect/Soft Tissue 3 3 2 2 Skin 32 3 9 3 2 8 5 3 2 Melanoma 29 28 8 2 8 3 3 2 Other 3 3 2 2 36

CLASS SEX TNM STAGE Total A N/A Male Female O I II III IV UNK N/A Breast 247 246 246 29 8 79 9 5 6 Female Genital 32 3 2 32 2 8 3 4 3 2 Cervis Uteri 5 5 5 2 2 Corpus Uteri 2 9 2 7 Ovary 4 4 4 2 Vulva 2 2 2 Other Male Genital 23 22 23 8 9 3 2 Prostate 8 7 8 5 8 3 2 Testis 4 4 4 3 Other Urinary System 66 62 4 53 3 28 2 8 6 4 8 Bladder 53 49 4 42 27 8 8 2 7 Kidney/Renal 9 2 4 3 3 Other 2 2 2 BRAIN & CNS 24 24 4 24 Brain (Benign) Brain (Malignant) 9 2 Other 2 2 5 7 2 Endocrine 8 7 5 3 6 Thyroid 2 2 Other 6 5 4 2 6 Lymphatic System 3 29 4 6 9 6 2 2 Hodgkin s Disease 2 2 2 Non-Hodgkin s 28 27 2 6 9 5 2 Unknown Primary 4 4 2 2 4 Other/Ill-Defined 37

AGE DISTRIBUTION - CMC-PINEVILLE 2 8 6 4 2 Age Range Male Female - 9 2 2-29 4 3-39 9 6 4-49 24 69 5-59 36 94 6-69 63 9 7-79 48 77 8-89 28 37 9-99 5 7 TOTALS 25 45-9 2-29 3-39 4-49 5-59 6-69 7-79 8-89 9-99 AGE RANGE Male Female RACE DISTRIBUTION - CMC-PINEVILLE White Black Other Race Cases Percent White 53 8% Black 85 3% Other 42 7% TOTAL 63 % 38

CASES TNM STAGE DISTRIBUTION - CMC-PINEVILLE 25 2 24 5 32 5 66 76 65 54 33 I II III IV UNK N/A TNM STAGE TNM Stage NBR Cases Percent 66 % I 24 32% II 32 2% III 76 2% IV 65 % UNK 33 5% N/A 54 9% TOTAL 63 % CASES STAGE BY SEX - CMC-PINEVILLE 2 5 Stage Male Female 25 4 I 45 59 II 32 III 29 47 IV 33 32 UNK 7 6 N/A 34 2 TOTALS 25 45 5 I II III STAGE IV UNK N/A Male Female 39

STATE AND NATIONAL COMPARISONS - CMC-PINEVILLE 4 35 3 25 PERCENTAGE 2 5 5 Breast Lung Prostate Colorectal Bladder NH Lymphoma Corpus Uteri Melanoma Leukemia Cervix All Other Kind of Cancer CMC-Pineville NC Estimates U.S. Estimates Type CMC NC US TOTAL 42,27,479,35 percent of total Breast 38% 3% 3% Lung 9% 6% 5% Prostate 4% 7% 3% Colorectal 8% % % Bladder 5% 4% 5% NH Lymphoma 4% 4% 4% Corpus Uteri 2% 2% 3% Melanoma 4% 5% 5% Leukemia % 3% 3% Cervis % % % All Others 25% 34% 29% 4

COUNTY DISTRIBUTION OF CANCER CASES - CMC-PINEVILLE. Alexander 7. Chesterfield, SC 3. Gaston 5 2. Anson 8. Catawba 6 4. Newberry, SC 3. Cherokee, SC 9. Cleveland 2 5. York, SC 8 4. Burke. Horry, SC 6. Lincoln 3 5. Chester, SC 4. Kershaw, SC 7. Mecklenburg 327 6. Cabarrus 2 2. Lancaster, SC 2 8. Rowan 9. Rutherford 2. Union 42 2. Yancey 9 9 2 2 4 8 6 6 3 3 5 5 4 7 327 8 6 2 3 5 2 8 42 2 2 2 7 4 NORTH CAROLINA............... 45 SOUTH CAROLINA............... 2 OTHER/OUT OF STATE............. 4 TOTAL........................63 4

Major Site Report: LUNG CANCER Lung cancer is a malignant proliferation of cells derived from bronchopulmonary epithelium, and is the leading cause of cancer death in both men and women in the United States. It accounts for approximately 4 percent of new cancer diagnoses and 28 percent of all cancer deaths, which reflects the highly lethal natural history of the disease. Over 6, deaths due to lung cancer are expected in the United States in 22, which is more than that expected from breast, prostate and colon cancers combined. Fortunately, the incidence rate of lung cancer has been declining in recent years, which reflects societal changes in smoking behavior (Figure ). The rate for men STUART SALMON, MD peaked in 984 at 2 cases per,, with death rates dropping by more than 2.5 percent per year in recent years. Incidence rates for women have been slower to decline, but death rates have been dropping by almost percent per year since 24. However, these positive changes may not be as fully realized across all ethnic groups and communities. The predicted incidence rate in North Carolina for 22 ( per,) is well above the current national average. The national incidence rate for African Americans (approximately 95 per,) is higher than that of other ethnic groups. Cigarette smoking is by far the most important risk factor for developing lung cancer, and the risk increases with increasing quantity and duration of cigarette use. It is estimated that smoking is responsible for 8-9 percent of lung cancer cases, and smokers are approximately 2 times as likely to develop lung cancer as nonsmokers. No form of recreational smoking is safe: even cigar and pipe tobacco use will increase the risk of lung cancer. Other risk factors for lung cancer include exposure to second-hand smoke, radon, and occupational carcinogens like asbestos. Lung cancer is a disease that preferentially afflicts older patients with a median age at diagnosis of 7 years old nationwide. There were a total of 43 new lung cancer cases treated in the Carolinas HealthCare System (CHS) in 2, and the age distribution of those cases was similar to, but slightly younger, than that seen elsewhere in the National Cancer Data Base (NCDB) (Figure 2). However, the ethnic distribution of these patients differs significantly from the NCDB as a whole, with a relatively higher proportion being African American (Figure 3). Lung cancer is a heterogeneous disease consisting of different histologies with different natural histories. It is commonly divided into two groups: non-small cell carcinoma (NSCLC, 85 percent of the total), which consists of several histologies (adenocarcinoma, squamous cell carcinoma, large cell carcinoma and other rare subtypes), and small cell carcinoma (approximately 5 percent of the total, but declining in incidence relative to other histologies). The distribution of lung cancer subtypes in the CHS Cancer Network reflects national trends (Figure 4). Treatment and prognosis varies among subtypes of lung cancer. Prognosis for all subtypes of lung cancer is highly dependent upon tumor stage at diagnosis. Staging involves the determination of a cancer's size, its invasion into surrounding tissues, and the presence or absence of metastatic spread to lymph nodes and other organs. The stage distribution of new lung cancer diagnoses in the CHS Cancer Network is similar to that seen elsewhere in the United States (Figure 5). The treatment of choice for localized NSCLC is definitive surgical resection when medically feasible, but many larger localized cancers and those that have spread to regional lymph nodes (stage III disease) may not be amenable to an operation. In these cases, definitive radiation therapy, often with concurrent 42

chemotherapy, might still be given with curative intent, although most patients will eventually relapse and die of their disease. National Comprehensive Cancer Network (NCCN) guidelines suggest that appropriate patients with surgically resectable non-small cell lung cancers should also receive adjuvant chemotherapy (with or without radiation therapy), in an effort to improve survival. Lung cancers that have spread through the blood stream to other sites (stage IV disease) are usually considered incurable, and treatment is thus viewed as palliative (but potentially life prolonging), consisting of systemic drug therapies like chemotherapy. Stage IV NSCLC has a poor prognosis, with median survivals usually less than year despite therapy. In 29, 25 percent of NSCLC cases in the CHS cancer network were treated with surgery, compared to 28 percent of cases at all hospitals in the NCDB. Of those who did undergo surgery, 32 percent of patients in the CHS cancer network also received adjuvant chemotherapy compared to 26 percent in the national database. Small cell lung cancer is marked by a predilection for early systemic spread, and is therefore much less likely to be caught in an early stage appropriate for surgical resection. In 29, less than 5 percent of new small cell lung cancers in the CHS cancer network were treated with surgery, which mirrors the experience elsewhere in the United States. Large localized small cell lung cancers and those that involve lymph nodes in the chest but do not have metastatic disease outside of the thorax, may still be viewed as potentially curable with a combination of chemotherapy and radiation, although again most patients will relapse and die of their disease. Although stage IV small cell carcinoma can be very responsive to initial systemic chemotherapy, the responses tend to be short-lived, with rapid development of drug resistance, relapse, disease progression, and death. Five year NSCLC survival by stage for 246 patients from 26 treated in CHS is illustrated in Figure 6. Data from an additional 68 patients are excluded from this analysis due to missing follow-up information. The survival curves are well separated by stage, but almost certainly under-represent actual survival outcomes due to a superior ability to track deaths than survivals, with relatively fewer deaths excluded from the data set. This analysis estimates a 28 percent three year overall survival and an percent five year survival for all NSCLC patients in the CHS cancer network, and an 8 percent five year survival for all small cell lung cancer patients. The treatment of lung cancer is rapidly evolving, and CHS remains committed to being on the forefront of medical technology. The rapid adoption of endobronchial ultrasound (EBUS) has led to improvements in diagnosing and staging thoracic tumors, while decreasing the need for more morbid diagnostic surgeries like mediastinoscopy. Most lung cancer operations within the system now utilize minimally-invasive Video- Assisted Thoracoscopic Surgery (VATS), with greatly reduced complication rates and recovery times compared to standard thoracotomy. Three-dimensional planning and conformal radiation techniques have led to improvements in the delivery of cancer-killing radiation while avoiding toxicity to surrounding tissues. Advances in our understanding of the molecular pathogenesisof lung cancer have led to the development of novel targeted therapies like erlotinib and crizotinib, with much better efficacy and improved tolerability in appropriate patients, compared to conventional chemotherapy. But despite these measurable improvements, lung cancer remains a deadly disease and will be a considerable challenge to our healthcare system for the foreseeable future. Ultimately, the most effective way to reduce the morbidity and mortality of lung cancer in the years to come will be further reductions in smoking behavior. 43

INCIDENCE OF LUNG CANCER IN THE UNITED STATES 992-29 (FIGURE ) 9 INCIDENCES PER, 8 7 6 5 4 3 992 994 996 998 2 22 AGE GROUP 24 26 28 Female Male Both 44

AGE DISTRIBUTION OF LUNG CANCER CASES 2 (FIGURE 2) 8 NUMBER OF CASES 6 4 2-9 Female 2-29 3-39 4-49 5-59 AGE GROUP 6-69 7-79 8-89 9 & over Male 4 35 3 PERCENTAGE 25 2 5 5-9 CHS 2-29 3-39 4-49 5-59 AGE GROUP 6-69 7-79 8-89 9 & over United States 45

DISTRIBUTION OF LUNG CANCER CASES BY RACE (FIGURE 3) White Black Hispanic Other UNITED STATES, 29 CHS DISTRIBUTION OF LUNG CANCER HISTOLOGIES CHS 2 (FIGURE 4) Small Cell Lung Cancer Adenocarcinoma Squamous Cell Carinoma Non-Small Cell Carinoma, NOS Large Cell Carinoma Bronchoalveolar Carinoma Other LUNG CANCER STAGE DISTRIBUTION CHS 2 (FIGURE 5) Stage I: Small tumors that have not spread to lymph nodes Stage II: Larger tumors or those that have spread to local lynmph nodes Stage III: Large tumors and those that have spread to regional lymph nodes Stage IV: Tumors that have metastasized to other sites Unknown 46

OVERALL SURVIVAL FOR 246 PATIENTS WITH NSCLC IN CHS SYSTEM DIAGNOSED IN 26 8 PERCENTAGE 6 4 2 Begin Year Year 2 Year 3 Year 4 Year 5 Stage I: 65 patients Stage II: 24 patients Stage III: 47 patients Stage IV: patients 47

Contact Us For more information on Levine Cancer Center Institute or to make patient referrals, please contact us at: 74-355-2884 or 8-84-9376 www.levinecancerinstitute.org Learn More About our Cancer Network Partners CMC-Mercy 74-34-5 www.cmc-mercy.org CMC-Pineville 74-667- www.cmc-pineville.org CMC-University 74-863-6 www.cmc-university.org Other Resources American Cancer Society 8-ACS-2345 www.cancer.org 48