The Cancer Collaboration 

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One Sunday evening a couple of Januarys ago, several Humboldt County cancer doctors got together for dinner at a home high atop a hill in Bayside. Ellen Mahoney, a renowned breast cancer researcher and surgeon, lives there with her husband, Luther Cobb, a general and thoracic surgeon. Mahoney pulled some of her frozen homemade sauce from the freezer, cooked up spaghetti and served it with salad. As the doctors ate, they talked about how they could raise the level of cancer care in Humboldt County to the same high standard enjoyed by residents in big urban centers such as, say, Palo Alto.

It was the first of a dozen or so dinner confabs members of the seven-doctor cancer care program had over the ensuing two years — dinners that became team-cooking affairs as the doctors, somewhat isolated in their practices, grew comfortable with each other. With time, the confabs gelled into a cohesive plan, parts of which the doctors immediately began acting on. And in December 2013, they announced a major component: They, through the local St. Joseph Cancer Care Program, had forged a formal collaboration with Stanford Medicine's Cancer Institute.

The collaboration sets up an infrastructure that will improve care for Humboldt's cancer patients and broaden research and academic opportunities for Humboldt and Stanford's doctors. Not only that, explained team leader Mahoney recently, the collaboration could end up being a model for rural cancer care in America.

That's a bright note in an oft-gloomy landscape of local healthcare, where such things as recruitment and retention woes, and patients traveling elsewhere for specialized care, can dominate the conversation.

The partnership is remarkable: It's Stanford's first formal collaboration with a rural community hospital (it has urban affiliates near and far). It was doctors who pushed for it, rather than administrators bent simply on marketing the Stanford brand. And it's collegial.

"It is not just university doctors coaching local doctors, but a relationship based on mutual respect and collaboration, and it is based on recognition of the excellent doctors we have here," says Mahoney. "We are working on building new ways of working together that other communities and other universities will find valuable."

It helps that Humboldt's oncologists already have informal working relationships with their Stanford counterparts (as they do with doctors at other university medical centers), in which, for instance, they confer by email on cases. But the formal collaboration — which will involve much more than occasional emails — might not have happened without Mahoney. And Mahoney might not have been here in Humboldt at all had she not suffered a terrible medical accident 21 years ago.

Mahoney, born in 1948, was raised in Monterey but, by the time she moved to Humboldt County in 2000, she had become deeply rooted in the Stanford community. The first of her family to graduate from college, she took it past the limit: Between 1967 and 1983, along with putting her first husband through law school, she completed her undergraduate, graduate and medical degrees, an internship and a residency at Stanford. She then started her own practice and later joined Stanford's clinical surgical faculty.

"To my shock and surprise, surgery was what interested me most," she says. "I liked the people who did it, I liked the work, and I liked the short feedback loop."

She also liked the challenge: It was rare, in the 1970s, for a woman to get into medical school — and she was pregnant when she applied. It was even rarer for a woman to become a surgeon.

In her first year post-residency, Mahoney opened a private surgical practice — the first woman to do that in Palo Alto. The phone didn't ring for the first three weeks, she says. But then the patients started coming, and by the end of the first year Mahoney had a successful practice.

Then she joined Stanford's surgery faculty, where she worked half time performing general, oncologic and trauma surgeries (she developed and ran the medical center's trauma service). She spent the other half of her time running her private practice. In 1986, she became Stanford's chief resident in surgery. She also helped design the medical school's first comprehensive cancer center. And, in 1994, after cross-country research and meetings with breast cancer patients, she and a patient opened the Community Breast Health Project in Palo Alto, a center where breast cancer patients could go for support and information. (The Humboldt Community Breast Health Project, founded in 1997, was modeled after it.)

"I was really, really busy and having a great time," Mahoney says.

But then she started having trouble walking. She was just 45.

"Long story short, I was walking around on an unstable spine," she says.

It was the return of a long-nagging problem. As a teen athlete, she'd been misdiagnosed with back problems and, the day after she graduated high school, had "an ill-advised" surgery that she says the doctor told her (ironically, in hindsight) would "keep me from being a paraplegic when I was 45."

"This operation was not necessary and it was done badly," she says. The bone grafts the surgeon did on her spine were compressing nerves. She had emergency surgery two years later but, still, she had chronic pain. Years of work further stressed her damaged spine.

So in 1993 she had another surgery, this time by one of the nation's best. It was "a tour de force operation, 17 hours," she says, two days after which she was able to stand up. It was fixed. But six days later, when she went in for a scan to make sure no clots were forming on her lungs, the medical attendants dropped her while transferring her from the gurney to the scan table.

"It was enough to send everything catawampus," she says. "And the blossoming of that complication led me to coming to Humboldt County."

Thirty-one hours' worth of multiple surgeries later, she could walk but her spine was fused in such a way that she lost her ability to bend at the waist. No longer could she perform the really involved operations — the pancreatic, liver and similar surgeries — that can be "like big athletic events" for the surgeons.

She resigned her post at Stanford but kept her private practice going and switched to taking only breast cancer cases. The surgeries were less taxing, and breast cancer was the most underserved cancer area at that time, Mahoney says. Plus, she'd already made a name for herself in the field and was colleagues with renowned breast cancer specialist Susan Love.

But now her second husband, Cobb, saw a chance to move. He was also a Stanford medical school graduate and served on its board and clinical faculty. He'd become restless, says Mahoney, and he told her the only reason they'd hung around the Bay Area so long was because she had been having such fun at work.

"He said he'd spent half his career in a medically over-served area, and he wanted to spend the second half in an area where he perceived they needed his skills more."

In 1997, Cobb moved to Humboldt County to join the medical staff at Mad River Hospital, where, today, he is chief of staff (he also is on St. Joseph's medical staff, has his own practice and last year was named president-elect of the California Medical Association). Mahoney stayed behind until their daughter finished middle school. In 2000, she closed her practice and moved to Arcata to join Cobb. Mahoney considered herself retired but, soon enough, grew "restless and bored."

She figured she could handle the smaller volume of breast cancer cases Humboldt was likely to provide, so she opened a practice.

Cancer care is a team effort. Medical oncologists treat cancer with chemotherapy and medication. Radiation oncologists use electron beams and other radiation therapies to destroy cancers. And surgeons — general, plastic and specialized cancer surgeons — do the operations to remove cancers and reconstruct areas operated on. Some cancers require just one of these treatments; some need two, and some need all three. And then palliative care doctors help patients deal with symptoms and end-of-life decisions.

"The exciting thing about Humboldt County is we've always had a strong cancer program," says David O'Brien, a family practitioner who was named president of the St. Joseph Health System-Humboldt County last August. "Our radiation oncologists are terrific oncologists, and we have amazing medical oncologists."

Mahoney says it took her a while, after she opened her practice here, to see this. She wasn't even sure if the pathologists — the folks who examine tissue samples in the lab to look for cancer cells — were up to snuff.

"I was used to university pathology," she says. "So, not knowing the guys here, I started sending my early biopsies back to Stanford for opinions — until the department chair at Stanford said, 'The pathologists there are really good, you don't have to keep sending biopsies to me.'"

She discovered, as well, that local radiation oncologist Michael Harmon's work was better than any she'd seen before, causing less distortion and skin changes; and that there was a perfectly competent plastic surgeon here to help her with breast reconstructions.

"These were really, really good people," she says.

But it's critical that specialists communicate with each other to design the best treatment program for each patient. Around the mid-2000s, Mahoney says, there was enough strife and dysfunction between the radiation and medical oncologists (some of whom have since moved) in Humboldt to prompt St. Joseph's administration to bring in an outside consulting group. One of the group's recommendations was for the hospital to appoint a medical director for oncology: Mahoney was dubbed.

She set out to bring central organization to the rather loosely connected community of local cancer docs.

"Not everybody in the medical community here was used to the concept of prospective team cancer care — where the whole team gets together and comes up with a plan tailored to what that patient needs," she says. "They were doing an older model, where the surgeon saw you first, and if they 'didn't get it all' then they'd send the patient to the cancer specialists. So it was surgery first, then radiation, then chemotherapy."

She thought the medical and radiation oncologists should be brought in early on a case.

"What was happening was, cases that should have been treated with radiation and/or chemotherapy before surgery, [the radiation and medical oncologists] were seeing after surgery. And, by then, sometimes they had lost the chance to do something that would have helped earlier on."

She says most of the other doctors agreed with her — they had to change. By 2012, they'd made progress in working more closely together. But they still weren't at that place, says Mahoney, where they were "delivering perfect care." Because Humboldt County is so remote, and flights out often prohibitively expensive, if a patient wanted a second opinion he had to drive at least six hours to get to the nearest big medical center with a cancer care program, such as Stanford, U.C. San Francisco or U.C Davis, find a place to park, maybe get a hotel room. And there likely would be little or no communication between the patient's out-of-town and Humboldt doctors. If there was a clinical trial going on — testing a new cancer treatment regime, for instance — that a Humboldt patient might be a candidate for, again, there were the expenses and that twisty highway to endure. It wasn't a pleasant prospect for people who might be wracked with nausea and pain, and was simply an impossible option for those without resources.

"I woke up one morning and said, 'Why shouldn't someone who's waking up here in Eureka, Calif., have the same care here as someone waking up in San Mateo?'"

So she started the dinners. Sometimes they were at her house, other times at one of the other doctors'. The more they met, the closer they grew, and the more inventive their dinners became. They were becoming a team.

"One time, Dr. Harmon found some chanterelles and brought them," Mahoney recalls. Join Luh, a radiation oncologist from Texas who joined Harmon's practice in 2007, cut them up, and someone else sautéed them.

Another time they all stood around the big wood block island in Mahoney's kitchen chopping up ingredients for make-your-own tacos. One night, Mahoney cooked recipes from "One Bite at a Time," the cookbook for cancer patients by Rebecca Katz. It was delicious.

"I made 'Yukon Gold Potato Leek Soup,' 'Baby Bok Choy with Sesame and Ginger,' probably some kind of roast chicken, and homemade green tea ice cream with mixed berries," she says.

One of the ideas they acted on quickly was to set up a central referral system at St. Joseph Hospital, so that primary care doctors could refer their patients to the cancer team instead of just one member of it. After a referral comes in, the whole team discusses a treatment plan for that patient.

And they decided that, in fact, there was no reason that a person in Eureka couldn't have the sa me standard of care as a person in San Francisco or New York City with a university medical center around the corner. They'd bring a big medical center's expertise to Humboldt. They'd find a university partner.

So they worked up a shopping list of things they wanted and brought it in person down to the cancer teams at Stanford and U.C. San Francisco medical centers. Both were interested, sent people up to check out Humboldt — "both universities were pretty impressed," says Mahoney — and then submitted their proposals. St. Joseph's cancer committee chose Stanford. Although UCSF had an affiliates program, it was a "you-do-what-we-say" package sort of deal, says Mahoney.

"Stanford was more willing to be flexible and creative with us and tailor to what we needed," she says.

The university had been searching for its first rural community partner, says Whitney Greene, director of business development at Stanford's Cancer Institute. Expanding its footprint, she says, would enable it to spread its academic expertise and help more people, but also to involve more people in clinical trials and thereby increase its power to discover new treatments. That, in turn, would make Stanford more competitive with other large, academic medical institutions also stretching out their feelers.

Humboldt was already on Stanford's radar, it turns out. Mahoney was there, for one — not only one of Stanford's own, but with such a high reputation she even was on Oprah Winfrey's O Team list of "extraordinary doctors, researchers, and women's health advocates." And Stanford's and Humboldt's oncologists already conferred by email on some of their cases. Most important, the medical director of Stanford's Cancer Institute (and past president of the American Society of Clinical Oncology), Douglas Blayney, had long been asking the same question as Mahoney: Why can't everyone have the same quality of cancer care? And why can't we use technology to bring it to them?

Greene says it was refreshing that it was Humboldt's doctors who were driving the push for university affiliation.

"We had looked at other locations for additional partners," says Greene. "The problem was, it was often the hospital administration pushing the relationship and the physicians were not necessarily supportive. It was almost like a branding thing. ... We've also seen communities where there's a lot of rivalry between physicians, where they don't necessarily want to all work together."

Humboldt was working on a true collaboration, she says, "based on their need and what their patients need."

The first thing that's going to happen is joint tumor boards. A tumor board is a cancer case conference, and typically Humboldt's cancer team holds its tumor board on Wednesdays, when doctors from each cancer discipline share their latest cases and, together, decide on the order of treatments for each patient. Often primary care and other types of medical providers attend. Stanford's cancer doctors do the same thing, although because of their patient volume they hold multiple boards throughout the week segregated by subspecialty, or type: head and neck cancers one day, for instance, gynecologic another day, and so on.

Now, Humboldt's and Stanford's doctors will be able to, via teleconference, sit in on each other's tumor boards. For the roughly 700 cancer patients that the local St. Joseph hospital system sees each year, especially ones with rare or complex cancers, the benefit of this larger think-tank examining their case could mean more efficient treatment. And for some of the ones who travel for second opinions and/or treatment — 82 of St. Joseph's patients did this in 2012 — it could mean fewer trips.

"And if, say, two or three weeks from [the time the board prescribed a treatment plan] we run into a snag with a case, we can go back to that joint tumor board and say, 'What do you think now?'" says Mahoney.

Some patients will still have to travel for surgery or certain treatments, says Mahoney — such as those with certain gynecologic cancers or complex blood-related cancers (such as acute leukemia). If they go to Stanford, the collaboration between doctors will smooth their transitions on both ends. And for patients who choose to, or in some cases have to, go to another big medical institution for part of their care, they'll still benefit from the joint tumor boards with Stanford.

A joint tumor board would have made it easier for Ann Marie Woolley to get a second opinion. Woolley, who is fine now, has had two cancers. She was treated in Humboldt for breast cancer, then later developed endometrial cancer — a complex case that required a specialist. She traveled to Redwood City for her operation, then had chemotherapy and radiation here in Humboldt. Then her cancer came back and she had a second surgery. Her Humboldt oncologists recommended she get a second opinion on what her post-surgical treatment regime should be this time. So she and her husband, John Woolley — a former county supervisor — traveled to Stanford.

"It was a $500 trip," says John. "And they didn't know us — it's kind of out of the blue that you go in. You're assigned a doctor. And they didn't change anything, it turns out. It would have been a lot easier if they had been connected to our oncologists up here."

In the future, Mahoney and Blayney want to set up three-way web conferences at the hospital in which a patient and local provider can confer live with a Stanford oncologist.

Another major component of the collaboration will be in-Humboldt clinical trials. Stanford plans to train someone here to identify local candidates for certain trials and help conduct them. That will enable more Humboldt patients to try something new and promising that might help them or a future cancer patient. Humboldt's oncologists could become co-researchers in trials. And Stanford will greatly expand its research base.

"We struggle to get 12 or so patients in clinical trials every year," says Mahoney. "We could get hundreds in clinical trials doing them here."

There's much more that Humboldt's patients and doctors will gain from this collaboration, including: genetic counseling; clinical faculty status at Stanford and access to Stanford's conferences, talks and medical library for our oncologists; and speakers from Stanford giving academic talks up here in Humboldt.

Stanford's oncologists, meanwhile, are eager to learn from Humboldt's population.

"There's a large Native American population in your area that we don't see here," says Blayney, as an example. "So we hope to learn some of the nuances of cancer care in that population. We know in other Native American populations that certain cancers are more common, things we don't see — gall bladder cancer, particularly. We look forward to learning how that transfers into your group in your area.

"Secondly, the support systems that the patients have with both family and community are likely much different in a rural area, and we hope to learn and teach our trainees about that."

One aspect likely related to that rural culture is the rare and complex cancers that occur in Humboldt.

"If you look at the California Department of Public Health's statistics," says Mahoney, "you can tell we get more advanced cancers by stage."

The reason, she and others suspect, is that Humboldt people are tough.

"They just keep chopping wood and start resting more," she says, if they're feeling more tired than usual. As Linda Rasmussen, assistant nurse manager for the St. Joseph Cancer Care Program, puts it, part of the reason for this toughness could be Humboldt's heritage of "Native Americans, gold seekers, adventurers, hunters, farmers, and ranchers." And the other part could be because Humboldt's median income (about $58,000 for a family of four) is nearly $20,000 below the state median, and almost a third of the county's residents live in rural areas, far from even the local hospitals.

"... the end result is a community culture consisting of people who don't call the doctor early," Rasmussen says.

A huge benefit both Stanford and Humboldt's docs hope to come from this collaboration is, in fact, a better educated public that begins to take better care of itself.

Improving cancer care in Humboldt is a big vision, and it seems to be coming together. But Ellen Mahoney is thinking this could lead to something even bigger: a complete rejuvenation of Humboldt's economy.

Simply put, if a bunch of well-off, aging but active folks living in nice homes in, say, Palo Alto are looking for a quiet, rural place to retire — maybe they'll choose Humboldt if they know it's got a great cancer program in addition to lovely trees and ocean and restaurants. Mahoney envisions droves of active seniors parking their Bay Area equity in cute Victorian fixer-uppers, hiring local renovators, buying local art and so on, creating a snowball effect of jobs and industry and liveliness that would make Humboldt an even more desirable place to live.

Maggie Kraft, executive director of the Area1 Agency on Aging, likes the idea but has her doubts. Kraft had cancer a decade ago and says better collaboration between her doctors could have eliminated some of the confusion during her treatment. But she says she can't envision healthy retirees moving here just because of a great cancer program.

"Nobody thinks they're going to get cancer," even retirees, she says. But retirees do know they're likely going to need certain, everyday things, including doctors who take Medicare, access-friendly housing once they're too frail to deal with a big property, help with laundry and shopping and more.

"Also, to make this a retirement mecca, I think we'd have to increase the temperature at least 15 degrees," Kraft says.

Even so, more coordinated care and a healthier population can't hurt the county. And the teamwork Mahoney and her six colleagues have worked so hard on is already keeping some good doctors from leaving here. Some of the team have consolidated their offices, and Mahoney says one day they'll all be under one roof.

"Some of us have had offers to go other places," Mahoney says. "I have. Join Luh has. And we decided to stay here because we like this team."

Luh agrees that the team is inspiring.

"In academic medical centers you're forced to [work as a team]," he says. "In a community, though, it's different: You've got all these separate practices that traditionally work like silos and don't talk to each other. ... Here we are in Humboldt County, with all these different practices, and we voluntarily work together. And that is really refreshing."

But Luh's also tied to Humboldt because he likes Humboldt. It was his wife's idea to try it; she thought it a good place to raise kids. He dragged his feet, and was a little put out the first time he came here to interview for the position. The airline lost his luggage, which contained his suit and tie, so he showed up in just a shirt and jeans.

"But Dr. Harmon just said, 'That's OK, it's Humboldt County,'" recalls Luh.

He and Harmon hit it off. And Luh was impressed that Humboldt had some high-end technology that even the big cancer center in Texas where he trained didn't have, including a combination PET-CT scanner and huge, easily accessible computer monitors.

On his last night of that first visit, as he was walking through Trinidad back to the scenic bed and breakfast he and his wife and their 11-month-old daughter had been put up in, he passed a crab fisherman carrying two grocery bags full of Dungeness crabs. The man told him he couldn't sell them at Murphy's because the market had enough crab already. So Luh asked if he could buy his two biggest.

Luh brought the crabs back to the inn, cooked them up, and he, his wife and the innkeeper sat around the kitchen table cracking shells and eating the succulent, sweet meat.

After they moved here, Luh's wife, an allergist, opened her own practice.

Recently, a big hospital in Waco, Texas, asked Luh to come be its cancer program director.

"I thought about the heat" in Texas, Luh says. "I thought about the access [here] to the redwood trails. I thought about the beach. And I said, even though I miss TexMex, and even though I miss Shipleys Donuts — and I miss Southwest Airlines — there was just no comparison. I've got a pretty good gig here."

Luh says he hopes to retire here.

One morning in early January, Mahoney is standing in her dining room, in her home high up on the hill. She's a petite woman, nearing 66, with lovely dark blues, a gently serious gaze and youthfully shiny sandy brown hair — "My only asset in looks," she says, "is I haven't turned gray." This is where many of the dinners took place, where she and her colleagues crafted a plan to take better care of Humboldt's people. She looks out the large windows: The entire community of Humboldt Bay, and beyond, spreads out before her. Arcata, Eureka. On some days, she says, she can see waves breaking on Centerville Beach. Beyond her vision lie more communities, east to Trinity County, north up to Del Norte, south to the border with Mendocino.

"It gives me perspective every night I look out this window," she says. "We hear the oyster men on the bay when they're harvesting. We see the crab fishermen's lights out there. And I think, 'I've got a lot of responsibility.'"

Expanding Cancer Care

The collaboration with Stanford's Cancer Institute is one of several projects St. Joseph's Cancer Program is undertaking to improve care for local patients. All of these efforts will help the program meet standards set by the American College of Surgeons, which accredits it. And, they respond to many of the recommendations made late last year in a report by the Institute of Medicine — which described the cancer care system in the United States as being in a crisis.

They include:

• A community needs assessment, conducted by retired family physician Diane Korsower, to determine gaps in, or obstacles to, local care for cancer patients and survivors. Her data will be used to train "patient navigators" who will be assigned to patients to guide them through their treatment and recovery.

• Development of a STAR — Survivorship Training and Rehab — program, led by the cancer program's nurse manager Linda Rasmussen. Twenty trained professionals will provide therapy for cancer patients, most of whom experience physical changes from chemotherapy and radiation, such as numbness, muscle stiffness and fatigue. It launches this March.