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KAISER PERMANENTE

ANNUAL CANCER REPORT 2017

MEDICAL CENTER

THE PERMANENTE MEDICAL GROUP

CANCER COMMITTEEDECEMBER 2017

FRESNO

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OUR MISSION IS SIMPLE: Support our specialists in providing the best inpersonalized cancer care. Kaiser Permanente’s integrated health care systembrings together a team of specialized physicians and cutting-edge technologyto provide each patient with the best in personalized cancer care.

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OUR COMMITMENT to PatientsCancer care touches our lives both professionally and personally. It is a toppriority at Kaiser Permanente. All of our physicians work on cancer in one way or another—whether to prevent it, detect it early, treat it when we find it, care for thesurvivors, or comfort those who may pass away as a result of the disease. We’vemade huge strides and continue to challenge ourselves through our commitment to every patient.

OUR WORLD-CLASS Cancer Care Team Includes:• Experienced specialists who treat

high volumes of patients

• Support at every step of care: riskreduction, screening, diagnosis, treatment, and survivorship

• Seamless and timely carecoordination

• Cutting-edge technology

• Patient-centered care

Our specialists work collaboratively to ensure world-class cancer care treatmentand outcomes for every patient, by leveraging our expertise, investing in cutting-edge technology, and pushing the boundaries of what’s possible.

Cancer Care Achievements

Integrated Approach to Cancer Care……..5

Commission on Cancer Accreditation …...7

Kaiser Permanente’s Cancer Research

Paves the Way for Improved Outcomes…..9

Trends in Cancer Diagnosis……………..10

Appendix…………………………………..12

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Cancer Care AchievementsCancer care is complex. We simplify screening, diagnosing, and treating patients with cancerthrough our integrated approach to care.

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INTEGRATED Approach to Cancer CareAs one of the largest integrated health care systems in the United States, we can quickly adapt to advancesin treatment. We bring those benefits to our patients every day to perform thousands of treatments each year. At thesame time, we create truly transformational innovations. Both rapidly adapting and developing new advancementsis only possible by leveraging our specialists’ knowledge from many disciplines and medical centers linked together by our electronic health record system.

We continuously weave advancements in equipment and techniques with each patient’s medical history, preferences, and unique needs. This means wecan automatically review incidental findings, suchas a thoracic imaging study that can be reviewedby various experts. This process facilitates rapidand consistent follow-up on unexpected cancer discoveries at imaging.

Our expert care team will work together to:

• Review newly flagged cases

• Meet with each patient to discuss next steps, treatment options, and personalized carerecommendations

It is the same as getting a second, third, and fourthopinion at the start of the process.

Our integrative approach to care also allows us toapply the most effective screening protocols to savemore lives, such as using universal reflex genetictesting for Lynch Syndrome of all newly diagnosedcolorectal cancer patients.

Our multispecialty physician team will:

• Recommend multiple ways to provide patient-centered care

• Bring cutting-edge treatment to patients

This multidisciplinary approach is distinctive of ourmedical group and doesn’t exist in the fragmentedfee-for-service health care sector. We’re able tostandardize the best possible care, giving our patientstheir best chance to beat cancer.

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CANCER CARE represents a large portion of our work at Kaiser Permanente. Only heart

disease affects more people than cancer in the United States, and the number of cancer cases

is quickly growing to surpass heart disease soon. We have an opportunity that other health care

systems may not—to change that trajectory. The Commission on Cancer provides a foundation

to focus on key quality care standards and our cancer program can lead this change.

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COMMISSION on Cancer AccreditationThere are more than 1,500 Commission on Cancer (CoC) accredited cancer programs in the United States, representing only 30 percent of all hospitalsand treating more than 70 percent of all cancer patients. All Kaiser PermanenteNorthern California facilities are accredited or pursuing accreditation. To earnthis prestigious accreditation, a cancer program must meet or exceed 34quality care standards, be evaluated every 3 years, and maintain levels ofexcellence in the delivery of comprehensive patient-centered care.

When cancer patients seek care at a CoC-accredited cancer center, they gain access to comprehensive, state-of-the-art cancer care closeto home. Kaiser Permanente takesthis one step further. Our integratedhealth care system allows for truemultidisciplinary, end-to-end care,and treats cancer as a complex groupof diseases treated by a team of specialists. Because of this approach, patients have access to clinical trials,

new treatments, genetic counseling, and patient-centered services, including psychosocial support, patient navigation, and a survivorshipcare plan. We improve our patients’ quality of life—both before and after cancer. These integrated partnershipsresult in improved patient care.

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Clinical Trials Matter to UsWe’re proud to offer cancer patients access to cutting-edge treatment throughparticipation in clinical trials.

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Kaiser Permanente’s Cancer ResearchPaves the Way for Improved OutcomesWe’re recognized for participating in numerous clinical trials with national and international researchorganizations. All of our medical and radiation oncologists are investigators on our cancer researchteam. There are more than 70 clinical trials available to patients at any given time. Because of this, we offer patients access to cutting-edge treatment options and research in symptom management, screening, and prevention.

In 2014, Kaiser Permanente was awardeda 5-year grant of 10.4 million dollars fromthe National Cancer Institute (NCI) toconduct cancer clinical trials and cancercare delivery research studies. We joined4 other Kaiser Permanente Regions toform an NCI Community OncologyResearch Program (NCORP). This newprogram represents 1 of every 40 patientsin the United States and continues to bringcutting-edge treatment options to ourpatients while comparing existing cancertreatments on a patient-by-patient basis.

The new funding will allow Kaiser Permanenteto expand its focus on research into caredelivery by:

• Evaluating alternative treatment deliverysystems

• Examining disease prevention

• Exploring pain and symptom management

• Investigating disparities in cancer outcomesand how to eliminate them

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TRENDS in Cancer DiagnosisThe cancer registry is an essential component of the Commission on Cancer (CoC) accredited cancer program and an invaluable tool in the fight against cancer. Like all CoC-accredited facilities, Kaiser Permanente maintains a cancer registry and contributes data to the National Cancer Database (NCDB). This nationwide oncology outcomes database is the largest clinical disease registry in the world. All types of cancer are tracked and analyzed through the NCDB and used to explore trends in cancercare. CoC-accredited cancer centers, in turn, have access to information derived from this type of dataanalysis, which is used to create national, regional, and state benchmark reports.

Our cancer registry data aids in identifying trends, assists in program planning, and allows our continuous evaluation of cancer care.

Specialists at this hospital interface with patients throughout our system. Our specialists’ experiencewithin the system is summarized in Table 1.

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Table 1. Kaiser Permanente, Northern California RegionAll Cancer Cases Diagnosed 2012–16: All Behaviors, All StagesLeading Diagnoses by Year of Diagnosis (Ranked for 2016 Diagnoses)

SOURCE: Kaiser Permanente—Northern California Cancer Registry (09/14/2017)

PRIMARY SITE OR TYPE 2012 2013 2014 2015 2016 TotalBREAST 3,745 3,876 3,748 3,928 3,794 19,091

MELANOMA 1,759 2,023 2,265 2,475 2,519 11,041PROSTATE 2,608 2,436 1,415 1,705 1,712 9,876

LUNG/BRONCHUS 1,685 1,749 1,764 1,778 1,638 8,614COLORECTAL 1,530 1,554 1,677 1,635 1,619 8,015

URINARY BLADDER 791 841 865 893 893 4,283NON-HOD LYMPHOMA 743 725 850 829 830 3,977

CORPUS UTERI 696 648 758 739 802 3,643KIDNEY/RENAL PELVIS 585 602 579 705 701 3,172

BRAIN/OTHER NERVOUS 661 691 740 645 563 3,300PANCREAS 486 475 502 508 496 2,467

ORAL CAVITY/PHARYNX 445 465 508 517 485 2,420ALL LEUKEMIA 483 529 528 479 481 2,500

THYROID 415 393 411 474 437 2,130LIVER/INT. BILE DUCT 307 370 446 423 346 1,892

STOMACH 258 247 296 293 304 1,398OVARY 293 246 300 280 262 1,381

MYELOMA 250 243 257 268 236 1,254SOFT TISSUE/HEART 136 161 148 147 164 756

ESOPHAGUS 168 150 165 184 163 830ANUS/ANAL CANAL 150 164 180 186 162 842

VULVA 151 162 169 150 139 771TESTIS 94 105 120 131 119 569

HODGKIN LYMPHOMA 73 83 116 87 109 468OTHER ENDOCRINE 160 176 156 156 107 755

CERVIX UTERI 96 86 93 90 102 467OTHER SKIN 79 83 97 114 96 469

SMALL INTESTINE 74 78 82 87 89 410OTHER BILIARY 62 67 74 58 79 340

LARYNX 77 81 70 92 75 395ILL-DEFINED 658 644 568 520 430 2,820ALL OTHERS 401 397 418 433 424 2,073

TOTAL 20,119 20,550 20,365 21,009 20,376 102,419

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Prevention PROGRAMWe know quitting tobacco can be difficult. That’s why we offer our members a range of proven approaches to help them quit.

Working with a wellness coach by phone helps increase the likelihood of success by helping a member create –and stick with – a plan to quit tobacco.

Individual tobacco cessation counseling with a clinical health educator also increases a member’s chance of success. In addition, tobacco cessation workshops and classes are offered to members and to the community, free of charge.

Members are also eligible to receive tobacco cessation medications with a prescription from their doctor. Additional online resources in English and Spanish are available.

We leverage technology that prompts our physicians and staff to engage in conversations with members about their smoking status. For those who smoke, we provide guidance, support and resources to help them take the necessary steps toward quitting.

Follow up phone calls and care are provided to our tobacco cessation members to help them live well without tobacco.

Screening PROGRAMKaiser Permanente Fresno implemented the Lung Cancer Screening Program in 2017.

Patients eligible for lung cancer screening must be:

• Between 55-80 years AND

• A current smoker OR quit within the past 15 yearsAND

• Smoked the equivalent of a pack a day for 30years.

Eligible patients are referred to a pulmonologist-led class to better understand the process of lung cancer screening, including the benefits and risks.

Following the class, patients meet one-on-one with a pulmonologist to decide if lung cancer screening is the best choice for them. If it is beneficial for a patient to pursue this screening opportunity, he/she receives a low-dose CT exam annually to screen for lung cancer.

Since its implementation, 44% of patients who attended the class have decided to undergo lung cancer screening. While no cancers have been identified to date, 33% of those screened will be monitored closely based on the results of their initial screening.

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Quality IMPROVEMENTS

Perioperative Staging for Colon Cancer Patients

Under the leadership of Surgical Oncologist Nicole Hill, MD, our Comprehensive Cancer Care Committee aimed to improve preoperative staging for patients undergoing elective colon cancer surgery.

National Comprehensive Cancer Network’s guidelines indicate patients should have these preoperative tests: a carcinoembryonic antigen (CEA) test; a computerized tomography (CT) of the abdomen/pelvis; and a CT of the chest.

A review of 2014 and 2015 surgical cases showed there was an opportunity to improve in this area. By leveraging technology, our surgical team added prompts in Kaiser Permanente Health Connect, our electronic health record system, that allows providers to check whether these tests are complete. The tests can be ordered by the provider immediately if needed

Since initiating this quality improvement, the surgical team has documented a 273 percent increase in compliance.

High-Risk Breast and Ovarian Cancer Clinic

The Comprehensive Cancer Care Committee established a High-Risk Breast and Ovarian Cancer Clinic for patients identified as high-risk based on genetic screening.

Patient cases are discussed at a multidisciplinary conference where providers evaluate cases and discuss potential options that can be offered to the patient to aid in the care planning process.

Then, patients have an opportunity to meet with specialists, including a surgeon, plastic surgeon, gynecologist, and a genetic counselor to jointly decide on a care plan.

Previously, it required multiple visits to multiple locations for patients and providers to decide on a care plan. By establishing this clinic, patients experience a more streamlined process. Physicians and staff are also able to review regional reports showing potential members who require follow-up and care based on current screening guidelines.

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In the COMMUNITYKaiser Permanente Fresno physicians and staff regularly provide expertise to local television and print media about cancer advances and awareness.

We host a certified, year-round farmers market at our medical center every Wednesday for employees, patients and the community. Educational materials from American Institute for Cancer Research are provided to educate visitors about reducing cancer risk, preparing healthy meals, and managing weight.

Kaiser Permanente providers and health educators have booths to educate shoppers

about smoking cessation and other types of cancers and health conditions.

We proudly sponsor the Leukemia and Lymphoma Society’s Light the Night Walk and American Cancer Society’s Making Strides Against Breast Cancer Walk.

We also support the Art of Life Cancer Foundation with an art kiosk in the Art of Life Healing Garden at Woodward Park which displays artwork made by cancer patients and survivors.

ABOVE and BEYOND:Brandy Box-Noriega, MD, Christine Zhang, MD, and the Clinical Trials Team

Congratulations to Oncologists Brandy Box-Noriega, MD, and Christine Zhang, MD, for receiving a Certificate of Appreciation from the National Cancer Institute's (NCI) Community Oncology Research Program for patient enrollments in the NCI and Cancer Control clinical trial studies.

"For our patient population size, Kaiser Permanente Fresno has the highest percentage of patients (18.5 percent in 2016) who are offered and enrolled in clinical trials in the Northern California region," Dr. Zhang said. "Cancer is a scary diagnosis. It's very exciting for all oncologists to offer patients the newest treatment options. “

Because of KP's integrated health care delivery system, our oncologists have access to about 30 to 40 different clinical trial studies targeting a variety of cancers at any given time.

Dr. Zhang is part of the NCAL Oncology Clinical Trials Steering Committee, which consists of a team of oncologists, nurses, radiation oncologists, and research specialists who review and select clinical trials for our program.

"KP exercises a lot of discretion as to what clinical trials our patients are offered," Dr. Zhang said. "We want to offer new treatments that are most effective, less toxic and lead to a higher response and cure rate. Above all, it remains critical for providers to diagnose their patients early and get them in for the right treatment.“

Both Drs. Box and Zhang are quick to credit the entire Oncology team for their role in helping offer the latest trials to our patients.

Clinical Trials Research Nurse Mei-Fang Yu, RN, sees every patient who may qualify for a clinical trial to make sure they meet the specific criteria. She, along with Research Coordinator Sophie Masters, monitor patients while on the trials and have candid discussions with them about the benefits and risks.

"At any given time, we can have more than 100 patients enrolled in a clinical trial and most of them can be treated in Fresno," Yu said. "If a pharmaceutical study isn't available in our area, we can help the patient receive treatment at another KP facility.“

Above all, making sure patients get the right care at the right time remains the focus. "If we have a patient who urgently needs to get on a clinical trial, we all partner to make it happen. We work closely with Pathology, Radiology and many other department to help each other. It's so nice," Yu said. "Everyone makes it happen."

From left: Christine Zhang, MD; Mei-Fang Yu, RN; and Brandy Box-Noriega, MD

Comprehensive Cancer Care 2017 Committee Members

The Comprehensive Cancer Care Committee was established in 2016 in support of Commission on Cancer accreditation and to ensure an extraordinary care experience for members and patients living with cancer.

Cancer care requires a multidisciplinary approach and encompasses numerous physician and non-physician professionals who provide program leadership and represent the full scope of care.

Role Member Designee Chair Brandy Box-Noriega, MD Grace Inouye, MDDiagnostic Radiologist Sandra Carlsen, MD Priti Srivastava, MDPathologist Sidney Carpenter, MD Christopher Bui, MDSurgeon Nicole Hill, MD Subhendra Banerjee, MDMedical Oncologist Gabriel Rivera, MD Grace Inouye, MDRadiation Oncologist Giatri Dave, MD Li Liu, MDCancer Liaison Physician Nicole Hill, MD Subhendra Banerjee, MDCancer program Administrator Cheryl Nassrallah, RN, MSN Sofia Juarez, BSOncology Nurse Corina Avram, RN, ONC Frances Castellano, RNSocial Worker / Case Manager & Coordinator Rana Yamamura, LCSW Stasha Moreno, MSWCertified Tumor Registrar & Coordinator Michael Oehrli, CTR, MPA Iram Rana, CTRPalliative Care Duc Chung, MD Theresa Chang, MDGenetics Professional / Counselor Tamara Treisman, LCGC Jamie Fisher, LCGCCancer Conference Coordinator Rosa Granado Kimberly Capriola, MPHQuality Improvement Coordinator Elisa Porter, BA Christi Donsanouphit, MHACommunity Outreach Coordinator Carmen Arambula, RN, MSN Ann PetterssonClinical Research Representative Coordinator Mei-Fang Yu, RN Sophie MartinezRehabilitation Representative Maripet Caralde, PT May Cortez, PTSurgical Oncologist Reza Rahbari, MDAmerican Cancer Society Jennifer Giese

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Some photos may include models and not actual patients.© 2016, TPMG, Inc. All rights reserved. Regional Health Education. 06579 (Revised 10/17)