Baptist Cancer Institute 2014 Annual Report

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BAPTIST CANCER INSTITUTE CANCER PROGRAM

2014 ANNUAL REPORT

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TABLE OF CONTENTS

2

Cancer Committee Report

8

Tumor Registry Report

26

Tumor Review: Pancreatic Cancer

32

Tumor Review: Cervical Cancer

40

Quality Assurance

44

Clinical Research and Education

50

Spotlight in Cancer Care: Mark Augspurger, MD

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Baptist Cancer Institute 2014 ANNUAL REPORT

Baptist Cancer Institute (BCI) is affiliated with Baptist

Baptist Cancer Institute is one of the most active

Health, the only locally governed, faith-based health

clinical research institutes in the state of Florida,

system in Northeast Florida. Baptist Health, a

with open studies in breast cancer, lung cancer,

Magnet™ Health Care System honored for excellence

gastrointestinal malignancies, lymphoma, leukemia,

in patient care, is comprised of Baptist Medical

head and neck cancer, and brain tumors. We work in

Center Jacksonville, Baptist Medical Center Beaches,

collaboration with physicians across the state and the

Baptist Medical Center Nassau, Baptist Medical

nation to conduct clinical trials that lead to improved

Center South, Wolfson Children’s Hospital and

diagnostic approaches, reductions in toxicities and

Baptist Clay Medical Campus.

new ways to fight these often devastating diseases.

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CANCER COMMITTEE REPORT

CANCER COMMITTEE REPORT Troy H. Guthrie Jr., MD, CANCER COMMITTEE CHAIRMAN The 2014 Annual Report of the Baptist Health’s Cancer Committee will be the third consecutive year that it is published exclusively online. This 2014 published report will contain data, as always, compiled by the Tumor Registry from completely abstracted data on cases from the year 2013 and past. The Baptist Health adult hospitals—Baptist Medical Center Jacksonville, Baptist Medical Center South, Baptist Medical Center Beaches and Baptist Medical Center Nassau—are now all complete EMR hospitals and linked by telemedicine for cancer conferences. As Chairman of the Cancer Committee, we continue to follow recent annual reviews by making this current report both concise and informative. The cancer program has continued to evolve, offering

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Baptist Cancer Institute 2014 ANNUAL REPORT

a wide variety of multidisciplinary, cutting-edge

negative breast cancer, melanoma, pancreatic cancer

services and state-of-the-art research for cancer

and prostate cancer. Other unique programs utilizing

patients in Northeast Florida and Southeast Georgia.

targeted therapy with tyrosine kinase inhibitors have

Programs in neuro-oncology, breast cancer and lung

been opened in lung cancer and the hematologic

cancer offer a high level of multidisciplinary care that

malignancies. Research studies are offered through

translates into patient satisfaction during their

the auspices of the National Cancer Institute’s clinical

diagnosis, treatment and years of survivorship.

study groups, as well as pharmaceutical-sponsored industry trials.

Baptist Health has continued to provide a wide variety of cancer treatments and educational

Screening programs in breast cancer, colon cancer,

programs for both physicians and public. At Baptist

prostate cancer and skin malignancies continue to

Jacksonville, the palliative care program has

expand as screening programs for the public are

continued to expand. The program now includes two

offered with active intervention for malignancies

physician providers who help cancer patients

found. The genetic assessment program under the

transition from active treatment to a high quality of

leadership of Melinda Fawbush, MSN, ARNP, remains

supportive care. Close communications with hospice

extremely active concentrating primarily on breast

programs in Northeast Florida allow easy conversion

cancer. Multidisciplinary cancer conferences in breast

from outpatient palliative care to more intensive care

cancer are offered weekly, lung cancer bi-weekly and

in designated facilities. These supportive care

neuro-oncology on a monthly basis. These programs

programs allow patients and their families to make

are teleconferenced to satellite hospitals where the

every minute count toward the highest quality of life.

education can be reviewed by physicians and health

Clinical research programs continue to be extremely

care professionals in their own hospital. The Baptist

active at Baptist Cancer Institute with research

Jacksonville Tumor Board offers a review of all tumor

programs, including cutting-edge vaccine studies in

sites over a year’s period helping to fulfill the

breast cancer and melanoma, as well as development

American College of Surgeons requirement for

of unique immunotherapy treatment regimens,

physician education as well as certification as a

including monoclonal antibodies in lung cancer, triple

Community Cancer Center. Psychosocial support

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CANCER COMMITTEE REPORT

continues to be offered by George Royal, PhD, and

research, as well as goals of the Cancer Committee

more recently nutritional, physical therapy and

are reviewed. Current leadership for the Cancer

occupational therapy programs are offered for breast

Committee include Troy H. Guthrie, Jr., MD,

cancer patients through our multidisciplinary cancer

Chairman Cancer Committee; Mark Augspurger, MD,

program.

Liaison to the American College of Surgeons; Patricia Woods, RN, BSN, OCN, Quality Improvement

The Cancer Committee of Baptist Medical Center

Coordinator; Paul Oberdorfer, MD, Community

Jacksonville continues to meet quarterly to provide

Outreach Coordinator; Melissa McCarthan, RTCTR,

leadership, direction and review of all aspects of the

Tumor Registry; and Tammy Aguilar, BA, CCRP,

cancer program. This ensures that all services

Research Coordinator. At each quarterly meeting,

mandated by the American College of Surgeons

the Cancer Committee reviews, revises and ensures

continue to be offered and that appropriate

the current program goals meet requirements of the

documentation is completed. At each meeting, the

American College of Surgeons.

activities of the Tumor Registry and current clinical

800

1,484

1,560

1,624

1,656

1,779

1,744

1,253

1,265

1,139

1,138

1,041

972

965

865

928

807

688

1,000

764

1,200

964

1004

1,400

1102

1,308

1,600

1,467

1,800 1

1,630

Figure 1 Baptist Cancer Institute Analytic Cases by Year

No . of Pa ti en ts

4

600 400 200 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

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Baptist Cancer Institute 2014 ANNUAL REPORT

This Annual Report, as required by the American

Alliance and ACRIN NCI Research Groups, as well as

College of Surgeons, will include a retrospective as

the Radiation Therapy Oncology Group.

well as a prospective study of cancer disease sites,

Approximately, 40 percent of clinical trials performed

done to assess the quality of data provided by the

through Baptist Cancer Institute were NCI-sponsored

Tumor Registry. This year, I will review pancreatic

group trials and 60 percent were sponsored by

cancer as a retrospective study and Dr. Mark

pharmaceutical industry, continuing a trend since

Augspurger will review cervical cancer as a

2008. BCI continues to be one of the most active

prospective study. In 2013, more than 10 percent of

clinical research institutes in the state of Florida with

all analytic cases were reviewed on a prospective

open studies in breast cancer, lung cancer,

basis by physician volunteers to ensure continued

gastrointestinal malignancies, hematologic

quality and timeliness of data entered into the Baptist

malignancies, melanoma and brain tumors. The BCI

Tumor Registry. In 2013, signaling a continued trend,

focuses on cutting-edge programs in immunology

there was a drop in the number of cases assessed

including monoclonal antibodies and cancer vaccines.

with the total number of analytic cases being 1,484

The BCI works in collaboration with physicians across

compared to 1,560 in 2012 (Figure I). This represents

the state and nation to conduct these clinical trials,

a drop of 76 cases from 2012. Currently, the Tumor

which led to improved diagnostic approaches,

Registry includes a total of 28,938 analytic cases

reductions in toxicities and possible new ways to not

accrued since 1990. In 2013, the cancer clinical

only palliate cancer, but lead the battle for cure of

research program included active participation in the

cancer. As Chairman of the Cancer Committee since

National Surgical Adjuvant Breast and Bowel Project,

2005, it gives me continuing pleasure to see the

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CANCER COMMITTEE REPORT

expansion of our cancer services offered in Northeast Florida and Southeast Georgia in the year 2013. The year 2014, as well as the coming year of 2015, we expect continuing development of cancer services including a Baptist Health System sponsored oncology program as well as a possible affiliation with hospitals in the region including St. Augustine, Florida, and Brunswick, Georgia. Our hope is to increase the services offered to cancer patients throughout the region.

Troy H. Guthrie Jr., MD CANCER COMMITTEE CHAIRMAN, MEDICAL DIRECTOR, EDUCATION AND RESEARCH BAPTIST CANCER INSTITUTE

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Baptist Cancer Institute 2014 ANNUAL REPORT

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TUMOR REGISTRY REPORT

TUMOR REGISTRY REPORT Troy H. Guthrie Jr., MD, CANCER COMMITTEE CHAIRMAN Since 1990, the Commission on Cancer of the American College of Surgeons has approved the Tumor Registry report at Baptist Cancer Institute. As part of their approval, the Tumor Registry collects data on cancer screening, analyzes the incidence, tumor sites, kind of treatments provided, and survival outcomes of all patients whose original pathologic diagnosis is at Baptist Medical Center Jacksonville or Baptist Medical Center South. This data is then entered into the Florida State Tumor Registry and ultimately accumulated at the national level as SEER data. This process enables the American College of Surgeons as well as the National Institutes of Health to understand trends, assess quality of care and ultimate outcomes of a local institution as compared to national

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Baptist Cancer Institute 2014 ANNUAL REPORT

standards. In addition, this collection of data enables

As you can see from Figure 1, since 2009, there has

the American College of Surgeons to continue to

been a continuous drop in the number of patients

accredit cancer centers by comparing their outcomes,

seen compared to each previous year. This decrease

in terms of diagnosis, stage, efficacy of cancer

in number of patients represents a disturbing trend.

treatment and ultimate survivor outcomes, to other

Since 1991, the Tumor Registry at Baptist Jacksonville

hospitals throughout the nation. This enables Baptist

has seen a total of 28,938 analytic cases. Similar to

Cancer Institute, through the Tumor Registry, to

previous years, there continues to be a female

assess our level of care when compared to others

predominance of analytic cases with a total of 923

both within the state of Florida and on a national level

female cases compared to 561 male cases making the

to see if our standards of care are met. This also

total of 1,484 cases for 2013 (Figure 3). Much of this

enables Baptist Cancer Institute to assess areas where

drop represents the continued decrease in prostate

quality improvement is needed to address deficits

cancer cases compared to previous years. The female

within our program.

predominance represents the preeminent breast health care program attracting a disproportionate

The registry assists the Cancer Committee with

number of breast cancer patients as well as our strong

evaluation of outcomes, quality of medical care, and

gynecologic oncology program, which gives a higher

assessment of treatments in terms of recurrence and

incidence of gyn malignancies seen within the Baptist

survival outcomes. Currently, the Baptist Tumor

Health System. Figure 4 demonstrates the primary

Registry is accumulating data from both Baptist

sites at Baptist Jacksonville, with the five most

Medical Center Jacksonville since 1990 and Baptist

common sites including breast at 28 percent of all

Medical Center South since 2005. Physician

cases seen, lung 12 percent, female genital tract 11

volunteers from both hospitals assist the Tumor

percent, prostate 10 percent and colorectal at six

Registry in assessing the accuracy as well as

percent. Brain and other CNS sites represent a

timeliness of analytic case data by reviewing 10

disproportionate five percent of cases, as does

percent of all cases in 2014. Figure 2 demonstrates

melanoma at three percent, which demonstrates the

the number of cases accumulated from 1990 through

strong treatment programs for those malignancies at

2013 at Baptist Medical Center Jacksonville.

Baptist Jacksonville.

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TUMOR REGISTRY REPORT

Figure 4 Primary Sites: Baptist Medical Center Jacksonville (2013)

Figure 3 Male & Female Malignancies: 2013 (Baptist Jacksonville)

Total

%

Male

Female

Breast

416

28%

0

416

Lung

172

12%

74

98

Female Genital

156

11%

0

156

Prostate

139

10%

139

0

400

Colorectal

93

6%

47

46

200

Brain & CNS

68

5%

24

44

Other Sites

68

5%

53

15

Blood & Bone Marrow

55

4%

36

19

Urinary Bladder

49

3%

40

9

Melanoma

45

3%

26

19

Lymph Nodes

35

2%

19

16

Kidney

34

2%

22

12

Pancreas

34

2%

15

19

Thryoid

28

2%

7

21

Head & Neck

20

1%

16

4

Unknown Primary

20

1%

9

11

Stomach

19

1%

9

10

Liver

17

1%

11

6

Esophagus

16

1%

14

2

1,484

100%

561

923

923

Site S

1,000 800 600

561

No . of Malign an c ies

10

0

Male

Female

Total

Figure 5 demonstrates the primary sites seen at

of tumor sites of Baptist South compared to Baptist

Baptist South, which has a somewhat different

Jacksonville probably represents differences in

distribution with breast being 22 percent, lung 12

physician availability with colorectal surgery, and

percent, colorectal 12 percent, thyroid seven percent

endocrine surgeons and urologic surgeons having

and kidney six percent. This difference in distribution

a strong presence on the Baptist South campus.

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Baptist Cancer Institute 2014 ANNUAL REPORT

Figure 5 Primary Sites: Baptist Medical Center South Jacksonville (2013)

Site

Total

%

Male

Female

Breast

117

22%

1

116

Lung

66

12%

25

41

Colorectal

62

12%

30

32

Thryoid

39

7%

13

26

Kidney

35

6%

26

9

Other Sites

31

6%

19

12

Urinary Bladder

29

5%

17

12

Blood & Bone Marrow

26

5%

12

19

Pancreas

24

4%

12

14

Lymph Nodes

20

4%

9

11

Female Genital

14

3%

0

14

Head & Neck

14

3%

12

2

Melanoma

12

2%

9

3

Prostate

11

2%

11

0

Liver

10

2%

5

5

Stomach

9

2%

5

4

Esophagus

7

1%

6

1

Unknown Primary

7

1%

2

5

Brain & CNS

6

1%

4

2

539

100%

218

321

Total

The cancer research program at the Baptist Cancer

Radiation Therapy Oncology Group, which is an NCI

Institute includes active participation by medical

sponsored radiation oncology group. At any one time

oncology in both National Cancer Institute (NCI)

on the campus, approximately 40 to 50 cancer

sponsored research cooperative groups as well as

research studies are offered to patients by medical

pharmaceutical industry sponsored trials, and

oncology and radiation oncology.

radiation oncology’s continued participation in the

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TUMOR REGISTRY REPORT

Figure 6 Comparison Data with Florida and United States

Organ Site

Baptist Cancer Institute

Florida

United States

Breast

28%

13%

14%

Lung

12%

15%

14%

6%

3%

4%

10%

15%

14%

6%

9%

9%

Female Genital Prostate Colorectal

Figures for Florida & U.S. are estimated from The American Cancer Society /Cancer Facts & Figures 2013

Figure 6 represents the five most prevalent tumor

U.S. percentage respectively. Again, noted since

sites seen at Baptist Cancer Institute compared to

2005, colorectal cancer incidence at six percent is low

prevalence in Florida and in the United States. As can

compared to the U.S. and Florida incidence of nine

be seen, breast cancer is disproportionately

percent.

represented at Baptist Health at 28 percent compared to Florida’s average of 13 percent and the U.S.

These cancer incidences represent trends in patient

average of 14 percent. Lung cancer is slightly low at

referral as well as physicians available and research

12 percent compared to 15 percent in Florida and 14

programs available on the Baptist Jacksonville

percent in U.S. data. Prostate cancer at 10 percent is

campus. The high incidence of breast cancer

significantly low compared to the 15 percent

represents a strong breast health program with the

incidence in Florida and 14 percent at the U.S. level.

area’s premier breast imaging program, surgical

Female genital tract as stated previously is slightly

expertise and unique radiation facilities with the

disproportionately increased at six percent compared

INTRABEAMÂŽ intraoperative radiation therapy

with three percent and four percent at the Florida and

program as well as multiple research programs in

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Baptist Cancer Institute 2014 ANNUAL REPORT

breast cancer offered by medical oncology. The

decline in number of analytic cases represents a

increased numbers of gynecologic cancers represent

disturbing continuous trend starting in 2009

a strong affiliation by the gynecologic surgeons to

(Figure 1). Currently, the Tumor Registry includes

Baptist Jacksonville. The very high incidence of

more than 28,938 analytic cases seen and accrued

neuro-oncology patients represents the premier

since 1990. In 2013, a total of 90 patients were

physicians, including neurosurgery, and surgical

accrued to research studies between medical

facilities located at Baptist Jacksonville. Melanoma

oncology groups as well as radiation oncology.

patients from all over the region are attracted by the

Approximately 30 percent of the accrued patients

unique immunotherapy research programs offered

were to NCI-sponsored groups and 70 percent to

through Baptist Cancer Institute and again increased

pharmaceutical industry studies. Other Baptist

the percentage of patients expected within the

cancer activities include:

system.

• Major conferences for oncology nurses • Prevention and community education programs

This year, Dr. Mark Augspurger will provide the prospective review of a cancer site reviewing cervical cancer. I will provide the retrospective review for pancreatic cancer for the years between 2008 and 2013. These reviews are required by the American College of Surgeons for accreditation. During 2013, the Tumor Registry performed at an outstanding level being both short of personnel and having to undergo a change in facilities from the Hill Breast Center to

• Continued participation in the American Cancer Society and Leukemia and Lymphoma Society Committees • Special oncology nursing programs for community support of education in breast and lung cancer • Smoking cessation assistance programs for the community as well as employees of Baptist Health • Cutting-edge prostate cancer treatment programs

the Reid Building. During this time, they ensured

including seed implants and the state-of-the-art

that physician volunteers reviewed 10 percent of all

da Vinci ® Robotic Surgery unit

analytic cases as required for certification. In 2013, there was a drop in cases from 1,560 to 1,484. This

• Continued expansion of the stereotactic radiosurgery radiation program with a marked

13

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TUMOR REGISTRY REPORT

increase in the number of body sites being treated • Continued expansion of the limited breast radiation program using the INTRABEAM® technique • Continued expansion of the digital breast cancer screening program with completely centralized

and the Radiation Therapy residents at Mayo Clinic Jacksonville • Continued expansion and utilization of the comprehensive breast health program with nurse coordinator at Baptist Jacksonville, Baptist South and Baptist Beaches

diagnostic reading at the Hill Breast Center

• Rapid expansion of the neuro-oncology program

• Participation in inpatient quality improvement

with continued expansion of the radiosurgery

programs, including infection control • Expansion of the chemotherapy and radiopharmaceutical embolization programs for

program, as well as increased sophistication of the neurosurgery suites and continued expansion of neuro-oncology clinical research studies

treatment of liver malignancies • Continued participation of indigent programs, including the highly successful We Care Jacksonville program • Continued expansion of a hospital-based chemotherapy infusion unit • On-site involvement of hospice and palliative care programs for optimum support for both the cancer patient and their family • Continued expansion of the Genetic Risk

As Cancer Committee Chairman, I continue to be extraordinarily pleased by cooperation among Baptist Health administration, physicians and patients in their effort to develop the highest quality cancer program in Northeast Florida. The Baptist Health System, as part of their continued effort to upgrade the cancer program, in 2015, will institute their own medical oncology service as well as radiation oncology and gynecologic oncology programs exclusively serving patients through Baptist Health. We can expect in

Assessment Screening program, now focusing on

2014 and 2015 to develop a centralized, MD

breast cancer but also including melanoma and

Anderson-associated oncology program, which

colon cancers

bodes well for the future.

• Continued active participation in the oncology training program for the medical oncology fellows from the University of Florida Jacksonville

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Baptist Cancer Institute 2014 ANNUAL REPORT

BREAST CANCER In 2013, similar to previous years, the number of breast

oncology programs for breast cancer patients. Despite

cancer cases seen at the Baptist Cancer Institute

this slight decline in the number of breast cancer

decreased slightly compared to 2012. In 2012, there

patients seen at Baptist Jacksonville, it still represents

were 440 cases compared to 416 cases in 2013.

a disproportionate share of breast cancer patients seen

Similar to previous years, the number of early stage

on campus (28 percent of all cancer cases) compared

breast cancer cases continued to be high (Figure 7).

to the Florida and the U.S. average. With the

With Stage 0, or ductal carcinoma in situ, being 74

continued development of the Baptist Cancer Institute

cases or 18 percent. Stage I accounted for 46 percent

in the coming years of 2015 and 2016, and affiliation

and Stage II for 24 percent or a total of 88 percent of

with MD Anderson, a resurgence in the number of

patients having early stage or non-invasive breast

breast cancer patients would be expected. Within the

cancer with the vast majority of those patients after

planned move further in the future to an independent,

treatment having a normal life span. Only 30 cases or

free-standing cancer institute, this would likewise

7.5 percent were Stage III, which is locally advanced,

attract more patients to the preeminent Breast Health

and only 20 cases or 4.5 percent were Stage IV, or

Program at Baptist Cancer Institute. Other reasons for

metastatic, at presentation. Of these 416 cases only

seeing a disproportionate share of breast cancer

four lacked identification to stage properly and are

patients at the Baptist Cancer Institute include the

classified as unknown stage. This slight decline in the

unique intraoperative radiation program at Baptist

number of breast cancer cases seen at Baptist Medical

Jacksonville using the INTRABEAM速 for immediate

Center Jacksonville most likely represents transfer to

radiation of early stage breast cancer patients at the

facilities at Baptist Medical Center South and Baptist

time of surgery. Likewise, the multidisciplinary breast

Medical Center Beaches since both participate in the

conferences held on a weekly basis at Baptist

Baptist Breast Health Program and have increasingly

Jacksonville and Baptist South are attractive to women

developed sophisticated surgery and medical

who desire a multidisciplinary approach to their breast

15

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TUMOR REGISTRY REPORT

cancer. Cutting-edge research within the breast

cancer radiation from the MammoSite or use of

cancer field offered through the Baptist Cancer

brachytherapy to the external INTRABEAM®

Institute has included a unique protocol using a

intraoperative therapy which decreases the time

breast vaccine for locally advanced recurrent breast

needed for radiation for selected patients with small

cancer as well as a monoclonal antibody for triple

breast cancers. During 2013, Baptist Cancer Institute

negative breast cancer. The opportunity to participate

also offered an annual conference focusing on breast

in clinical research has attracted women throughout

cancer as it relates to primary practitioners as well as

the region.

educational programs including “Dessert and Discussion” for the public.

The Genetic Risk Assessment Program led by Melinda Fawbush, MSN, ARNP, has likewise added depth to

Dr. George Royal, PhD, Clinical Psychologist for the

the Breast Health Program with both preoperative

Baptist Cancer Institute, also continues to see a

and postoperative genetic risk assessment to help

disproportionate number of patients with breast

women make choices in the type of surgery and long-

cancer who need psychological support during this

term planning after a diagnosis of breast cancer.

calendar year.

Trends seen in the term of management in 2013

Figure 8 shows a continued slight drop in the number

include the increased utilization of survivorship

of ductal carcinoma in situ (DCIS) seen at Baptist

programs by our patients, which include nutritional

Cancer Institute during 2013. This, however,

support, lymphedema programs for palliation of

represents a success of the breast screening program

lymphedema, as well as yoga classes for relief of

which began in 2006 with DCIS being thought to

stress associated with the diagnosis and treatment of

represent a mid-stage between totally benign breast

breast cancer. Another trend is the utilization of early

tissue and invasive breast cancer which is usually

genetic assessment by our surgical team to help

found on screening and requires only local treatment.

guide women who appear at risk of a genetically

This local treatment allows the patient to avoid

derived breast cancer to plan for the type of surgical

undergoing adjuvant systemic therapy compared

procedure performed. Another program shift noted in

to those having more locally advanced Stage I or

2013 was the change in utilization of limited breast

Stage II breast cancer.

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Baptist Cancer Institute 2014 ANNUAL REPORT

17

Fi g u re 7 Baptist Cancer Institute Breast Cancer Staging: 2013

300

181

200

107

150 100

30

74

20

50

4

No. of Patients

250

0 0

1

2

3

4

Unknown

Stage

Figure BaptistCancer CancerInstitute InstituteBreast BreastCancerCancerDCIS Accrual Fi g u re 88 Baptist DCIS Accrual

10

39

74

79

55

40

50

55

56 30

17

20

29

30

23

25

40

34

43

50

8

No. of Patients

61

60

70 60

79

68

71

80

80

81

85

90 9

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year

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TUMOR REGISTRY REPORT

LUNG CANCER The number of lung cancer patients registered at

patients with early stage lung cancer who are

Baptist Medical Center Jacksonville decreased to 172

medically frail and inoperable. Likewise, the Baptist

in 2013. Unfortunately, similar to past years, the

Cancer Institute, through its multidisciplinary lung

number of incurable patients continues to be high with

cancer program, has a bi-weekly conference reviewing

12 percent being diagnosed in Stage III, of which only

all current cases in a multidisciplinary approach taken

10 or 15 percent will be long-term survivors, and 38

among thoracic surgery, radiation oncology and

percent being diagnosed in Stage IV, for whom all will

medical oncology. An active palliative care program is

be expected to ultimately die of their lung cancer

now run in the hospital through the leadership of

(Figure 9). This disproportionate share of advanced-

Andrew Daigle, MD, for those patients with lung

stage lung cancer patients is true throughout the State

cancer who require palliative care. In terms of clinical

of Florida and the United States. Although there was

research, the Baptist Cancer Institute has offered a

originally some hope that low-dose CT scanning

number of innovative research programs including

would be a way of early detection, currently the

targeted therapy protocols for patients with certain

number of false-positive scans requiring needless

mutations including EGFR and RET mutations. Another

biopsies, as well as the high cost of the screening CT

exciting research study opening up offers

scans, continues to derail this approach. Initiatives at

immunotherapy involving the monoclonal antibody

the Baptist Cancer Institute include an active

nivolumab for patients who have failed standard care.

stereotactic radiosurgery treatment approach for those

Again, the long-term hope for lung cancer patients,

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Baptist Cancer Institute 2014 ANNUAL REPORT

as well as patients with other malignancies, will be the

art clinical therapy as well as options for clinical

development of the BCI affiliation with MD Anderson

research programs that will improve the long-term

in the year 2015, which plans to bring a sophisticated,

prognosis of lung cancer patients.

multidisciplinary approach emphasizing state-of-the-

Fig u re 9 Baptist Cancer Institute Lung Cancer Staging: 2013

60

20

21

40

2

3

7

20

1

No . of Patients

59

64

80

0 0

1

Stage

4

Unknown

19

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TUMOR REGISTRY REPORT

FEMALE GENITAL CANCER In 2013, a total of 156 patients with female genital

evolves from the overwhelming utilization by women

cancers were accrued into the Tumor Registry

of standard American Cancer Society sponsored

at Baptist Medical Center Jacksonville. This large

screening guidelines as well as the increased

number of female genital tract cancers is due to

awareness of genetic risk patterns of ovarian cancer

the active participation by the Southeast Gynecologic

which result in earlier stage detection for this group

Oncology group in utilizing the modern clinical

of patients. Again, the continued development of

services as well as surgical facilities including the da

the Baptist Cancer Institute has seen the private

Vinci速 Robotic Surgery System at Baptist Jacksonville.

practice group Southeast Gynecologic Oncology

As one can see, (Figure 10) a large number of patients

become part of the Baptist Health System and as such

are early stage with 58 percent of patients being

will ultimately participate within the MD Anderson

Stage II. This high number of early stage cancers

associated multidisciplinary program.

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Baptist Cancer Institute 2014 ANNUAL REPORT

Fi g u re 1 0 Baptist Cancer Institute Gynecological Cancer Staging: 2013

89

100

60

21

24

40

8

11

20 3

No. of Patients

80

0 0

1

2

3

Stage

4

Unknown

21

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22

TUMOR REGISTRY REPORT

PROSTATE CANCER Unfortunately, in 2013, the Baptist Cancer Institute

particularly in the elderly or frail patient, as requiring

Tumor Registry continued to experience a steady

no therapy. Only five percent or a total of seven

decrease in patients with only 139 cases of prostate

patients had more advanced Stage III or Stage IV

cancer being accessed. This compares to a peak of

prostate cancer at presentation. Initiatives by Baptist

287 cases being seen in 2008. This drop of patients

Cancer Institute included continuing the prostate

represents a bleed out from the Baptist Health System

screening program during prostate cancer month in

which administration has begun to take steps to

September with the highly visible support of the

correct. Similar to all past years, Figure 11 shows the

Jacksonville Jaguars NFL team. Currently, there are no

vast majority of patients have localized highly curable

recognized, or at least highly utilized, methods of

Stage II with 70 percent, or a total of 91 patients,

prostate cancer prevention with all National Institutes

being accrued. This large number of Stage II patients

of Health (NIH) trials currently being negative in terms

represents a quirk in the diagnosis of prostate cancer.

of decreasing the incidence of prostate cancer. Baptist

As can be seen, there are no Stage 0, or in situ cancer,

Health continues to offer cutting-edge IMRT radiation

and Stage I cases are also limited with only 34 cases or

therapy, seed implants and the da Vinci速 Robotic

15 percent being noted. This occurs since Stage I and

Surgery to be utilized by the urologic surgeons and

Stage 0 are not clinically recognized or sometimes

radiation oncologists who practice at Baptist Health

considered by clinicians unlikely to affect the life span

facilities.

of the involved male patient and generally regarded,

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Baptist Cancer Institute 2014 ANNUAL REPORT

Fig u re 1 1 Baptist Cancer Institute Prostate Cancer Staging: 2013

91

100

60

34

40

5

3

4

4

5

20

0

No. of Patients

80

0 0

1

2 Stage

Unknown

23

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24

TUMOR REGISTRY REPORT

COLORECTAL CANCER In 2013, the total number of colorectal cancer cases

major clinical goals at Baptist Cancer Institute in the

accrued by the Tumor Registry continues to be

coming years should be to expand the awareness of

disproportionately less than that seen by other tumor

the public, as well as our referring primary care

registries in the State of Florida as well as the United

physicians, of appropriate colorectal screening along

States. Even more disappointing is the fact that, as can

with methods to implement these programs.

be seen in Figure 12, 49 percent of the patients are in

Hopefully, this will reverse the trend of

advanced stages, either Stage III or Stage IV, with 26

disproportionately high numbers of advanced

percent of patients being incurable Stage IV. This high

colorectal cancers seen at the Baptist Cancer Institute.

rate of advanced colorectal cancers seen at Baptist

Due to a number of obstacles, the goal of the Baptist

Medical Center Jacksonville represents a failure of the

Cancer Institute to establish a multidisciplinary

implementation of proper screening programs, since

gastrointestinal cancer program has not yet been

the majority of cancers found through American

successful. However, in the coming years, with the

Cancer Society or National Cancer Institute

development of an MD Anderson associated Cancer

recommended colorectal screening programs will

Institute this hopefully will be a primary goal both to

detect either early cancers or premalignant polyps.

prevent as well as treat our patients in a

Our Tumor Registry data mandates that one of the

multidisciplinary pattern.

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Baptist Cancer Institute 2014 ANNUAL REPORT

Fi g u re 1 2 Baptist Cancer Institute Colorectal Cancer Staging: 2013

23

20 20

3

10

0

No. of Patients

22

25

30

0

0

1

2

3

Stage

4

Unknown

25

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26

TUMOR REVIEW: PANCREATIC CANCER

TUMOR REVIEW: PANCREATIC CANCER AT THE BAPTIST CANCER INSTITUTE Troy H. Guthrie Jr., MD, CANCER COMMITTEE CHAIRMAN Pancreatic cancer is selected as a tumor site for the American College of Surgeons retrospective study.

In 2013, a total of 34 patients (or two percent of the 1,484 patients) were diagnosed with pancreatic cancer.

And in the years between 2008 and 2013, a total of 176 cases were seen. Unfortunately, similar to most tumor registries within the U.S., most of the cases were advanced adenocarcinomas of the pancreas and ultimately resulted in death. Currently, only five to 10 percent of patients diagnosed with pancreatic cancer will survive five years. Due to this dismal outlook, pancreatic cancer clearly needs future emphasis on diagnostic and treatment improvements.

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Baptist Cancer Institute 2014 ANNUAL REPORT

Pancreatic cancer in the U.S. represents an unusually

a slow but steady rise in the incidence of pancreatic

grim malignancy in terms of survival. Although about

adenocarcinoma has been noted. Genetic factors

42,000 cases will be expected to be diagnosed in

including the presence of BRCA1 or BRCA2

2014, 92 percent of those patients will be expected

mutations, Lynch syndrome, Cowden syndrome and

to die mostly within the first one to two years.

other familial cancer syndromes have also been

Ninety percent of all pancreatic cancers are

associated with increased occurrences of pancreatic

adenocarcinomas arising from the exocrine portion of

cancer. There also appears to be an increased

the pancreas and their bleak prognosis dominates the

incidence with African-Americans as compared to

outcome. Approximately eight percent of cancers will

Caucasians or Asians. Most series show a slight male

arise from endocrine portions of the pancreas and

predominance, although in the 176 cases seen in our

include a diverse group of cancers such as carcinoid

tumor registry from 2008 to 2013 there was

tumors, gastronomas, insulinomas and others. A few

essentially an equal sexual distribution with 89 female

other unusual variants will make up the rest of the

cases and 87 male cases.

pancreatic histology. In general, tumors of endocrine origin, while commonly found in advanced stages,

Pancreatic cancer, because of its vague and variable

have a much more indolent course and many patients

presentation, is usually diagnosed in advanced

live more than five years despite having metastatic

stages. Symptoms such as weight loss, vague

disease. The rest of this report will be devoted to the

abdominal pain and changes in bowel habits fail to

exocrine gland or adenocarcinomas of the pancreas.

lead the clinician to an early diagnosis of pancreatic cancer. Late symptoms such as jaundice usually

The exocrine adenocarcinoma of the pancreas has

denote advanced and incurable Stage III or IV. Stage I

diverse etiologies. These include both environmental

and Stage II pancreatic cancer are usually incidental

and genetic. Environmental factors shown to be

findings when CT scans of the abdomen are done for

associated with exocrine gland adenocarcinomas

other reasons besides looking for pancreatic cancer.

include cigarette smoking, obesity and long-standing

Tissue diagnosis is usually obtained by one of two

diabetes of more than 10 years duration. There is also

methods, either endoscopic ultrasound with a

a question whether or not chronic pancreatitis is

gastroenterologist doing a fine needle aspirate or CT-

associated with pancreatic adenocarcinomas. With

guided biopsy of a metastatic lesion usually within the

the rise of obesity in the American population, as well

liver. Many patients when diagnosed are debilitated

as the increasing age of the American population,

and have had significant weight loss.

27

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TUMOR REVIEW: PANCREATIC CANCER

Another obstacle to management of patients with

has invaded the celiac axis, stomach, spleen colon or

pancreatic cancer is the elderly patient population

superior mesenteric vessels. These could be with or

with most patients presenting in their sixth, seventh

without nodes. Stage IVB is when distant metastases

or eighth decade of life. In 2013, the median age of

are noted. As can been seen from the Baptist Cancer

presentation was 66 years old. Many of these patients

Institute data (Figure 13) for the years 2008 to 2013,

have multiple other serious medical problems further

our data appears somewhat skewed. Twenty-three of

hindering treatment.

the 176 patients were listed as Stage I, which represents 14 percent of the total. Stage II had 44

Current staging of pancreatic cancer follows a

patients or 27 percent of patients being listed in that

standard TNM system. Stage I being a T1 or T2,

stage. This is unusually high, but may represent the

which is either a tumor less than 2cm or greater than

fact that many of the patients being elderly and quite

2cm but completely confined to the pancreatic body

sick were never appropriately staged because they

proper. These are often endocrine gland tumors and,

received no treatment and often were given only

as stated earlier, often have a much more indolent

palliative care, so a need for complete staging did

course. Stage III is a T3, M0 malignancy in which the

not exist. Stage III locally advanced disease had 21

cancer has invaded a local structure such as bile duct,

patients, or 13 percent, and Stage IV had 63 patients

duodenum or para-pancreatic tissue. Stage IV is

or 40 percent. Most of these patients were probably

divided into a IVA where a T4 tumor is present which

adenocarcinoma patients and ultimately died.

Figure 13 Site by AJCC Stage Tabulation

Site

Total

Stg 0

Stg I

Stg II

Stg III

Stg IV

UNK

Pancreas

176

1

23

44

21

63

24

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Baptist Cancer Institute 2014 ANNUAL REPORT

Twenty-four patients were stage unknown, which

Cancer Institute (Figure 14), a total of 94 patients

again may represent being referred for palliative care

are listed as having no treatment which actually

only with no need for staging.

represents 53 percent of the patients; 34 had palliative chemotherapy only; 15 had palliative

Treatment for pancreatic cancer is multidisciplinary.

radiation plus chemotherapy; 12 were surgically

Surgery is reserved for Stages I, II and III and often is

resected for cure; and 11 had surgery plus

followed by radiation or chemotherapy plus radiation.

chemotherapy. In 10 patients, they were lost to

Many patients who are clinical Stage III patients at the

follow-up since no therapy is listed. Only 21 cases

time of exploratory surgery are found to be locally

received some form of surgery, thus only 13 percent

advanced and not operable for cure. Stage IVA

were actually treated for cure. This is consistent with

tumors, being extensive local disease, is usually given

national data. Figure 15 shows the survival tables for

either preoperative chemotherapy or preoperative

Stages I through IV patients from the Baptist Tumor

chemotherapy plus radiation and then restaged to

Registry. As you can see from this figure, at the end

see if they have become operable which will occur in

of 60 months (or five years) virtually none of Stage III

approximately 30 percent of patients treated in this

and IV patients were surviving, which again is

manner. Finally, Stage IVB is when physically fit

consistent with national data. Stage I, which probably

patients are given palliative chemotherapy using

consisted mostly of endocrine tumors, had a 63

primarily gemcitabine-based regimens, but survival is

percent long-term survival, which is again consistent

usually less than a year. As you can see from Baptist

with national data.

Figure 14 14 Site Site by

by Treatment Treatment Tabulation Tabulation Figure

Site

Total

None

Chemo

Radiation/ Chemo

Surgery

Surgery/ Chemo

All Others

Pancreas

176

94

34

15

12

11

10

29

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TUMOR REVIEW: PANCREATIC CANCER

Thus, the Tumor Registry information concerning

(Figure 16 ). Most patients, similar to national data

pancreatic cancer is, in general, consistent with

when appropriately staged, were Stage III or IV

national data. We had 176 patients seen between

representing late detection and advanced stage. Few

2008 and 2013. Of those patients, similar to national

of our patients, only 13 percent, received surgery,

data, there was an equal male and female distribution

which is the only recognized form of cure for

Figure 15 Survival Survival Rates RatesOver OverFive FiveYears Years(Cases (CasesDiagnosed Diagnosed 2003 - 2006) Figure 15 2003 - 2006) 100 95 90 85 80 75 70

Cumulative Survival Rates

30

65 60 55 50 45 40 35 30 25 20 15 10 5 0 0.0

1.0

2.0

3.0

4.0

5.0

Years from Diagnosis Stage 0

Stage I Sta

Stage II

Stage III Sta

Stage IV Stag

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Baptist Cancer Institute 2014 ANNUAL REPORT

pancreatic cancer, again similar to national data.

Figure 16 Cases by Gender

As can be seen from our survival figures Stages III and IV had less than 10 percent surviving after five years, which is again consistent with national data. The future for pancreatic cancer, if improvements will come, will involve earlier detection and discovery of new drugs such as molecularly targeted agents, which can meaningfully alter the dismal course of pancreatic cancer as it stands in 2014.

Site

Total

Male

Female

Pancreas

176

87

89

31

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32

TUMOR REVIEW: CERVICAL CANCER

TUMOR REVIEW: CERVICAL CANCER AT THE BAPTIST CANCER INSTITUTE Mark Augspurger, MD, RADIATION ONCOLOGIST Over the last few decades there has been a dramatic decline in the incidence of cervical cancer in the U.S. Despite this trend, it is estimated that in 2014, approximately 12,000 women will be diagnosed with cervical cancer and this disease will result in more than 4,000 deaths. The management of this disease is complex and may involve surgery, radiation therapy or chemotherapy depending primarily on the stage of disease at the time of presentation. This review will discuss the epidemiology, staging and management of cervical cancer and compare national data with patients treated through the Baptist Cancer Institute.

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Baptist Cancer Institute 2014 ANNUAL REPORT

Anatomy and Natural History

patient may experience bowel or urinary

The cervix is essentially a cylinder of smooth muscle

abnormalities, swelling in the legs, cough, shortness

located at the lowest portion of the uterus (womb).

of breath and weight loss.

The uppermost portion of the vagina will connect with the cervix. The center of the cervix is a hollow

Once a cervical cancer has been identified, all women

tube. The cells that line this tube are glandular while

should have a full history and physical exam

the cells that cover the outer cervix are called

performed by a gynecologic oncologist. Additionally,

squamous. The transitional zone is where these two

a chest X-ray, blood work and an examination under

cell types meet and is the location from where most

anesthesia are necessary. An IVP (intravenous

cervical cancers originate. The vast majority of

pyelogram) or CT scan of the abdomen and pelvis

cervical cancers (65-80 percent) arise from the

should be completed. PET imaging or an MRI of the

squamous cells. Once cancer develops, it can spread

pelvis may be of some benefit. In advanced cases, a

deep into the muscle layers or radially along the

cystoscopy and proctoscopy will be done. Although

surface. Eventually, it will gain access to the lymphatic

not part of the staging work up, an HIV test should be

nodal drainage system. Finally, the cancer can spread

considered.

through the blood stream to distant organs.

After the work up has been completed a stage

Presentation, Work up and Staging Fortunately, most cases of cervical cancer in the U.S. are identified at an early stage through screening with a Pap smear. The majority of these women will have no symptoms related to their cancer. As the tumor progresses, the most common symptom is abnormal (intramenstrual, postcoital or postmenopausal) vaginal bleeding. Also, women may complain of pelvic pressure or pain, pain with intercourse, or low back pain or vaginal discharge. In advanced cases, the

grouping can be assigned. There are two staging systems in use for cervical cancer. These systems are similar and correlate with each other. In both systems, disease that is confined to the cervix is classified as Stage I. If the tumor is less than 4 cm in size it is given an “A” sub-group designation. Bulky localized tumors over 4 cm are given a “B” designation. If the tumor extends into the tissues adjacent to the cervix, known as the parametria, or into the upper vagina, the tumor will be given a Stage II designation. Stage III cancers will reach the pelvic sidewall and interfere with drainage from the kidney. Also, a tumor that extends

33

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TUMOR REVIEW: CERVICAL CANCER

into the lower third of the vagina will be classified as

disease. This may be due to effective screening

Stage III. Stage IVA tumors will extend locally into

among our referring primary care physicians and

adjacent organs such as the bladder or rectum. Stage

referring gynecologists. (Figure 17)

IVB tumors will have spread outside of the pelvis.

In 2013, 24 new patients were diagnosed or treated

Risk Factors, Epidemiology and Prognosis

at the Baptist Cancer Institute for cervical cancer.

The development of cervical cancer is highly

Fortunately, the vast majority of these patients

correlated with an exposure to HPV (human

presented with an early stage of disease. Over a

papillomavirus) especially virus subtypes 16 and 18.

larger time period between 2002 and 2011, 156

This virus is transmitted through sexual activity.

patients with cervical cancer were entered into the

Therefore, the incidence of this cancer will correlate

Baptist Tumor Registry. Again, the trend among these

with age at onset of sexual activity, number of sexual

patients was to have early stage cancer. When

partners and a history of sexually transmitted disease.

compared to the remainder of the U.S., the Baptist

A patient’s immune status will play a role in the

patient population tended to have less advanced

Figure 17 Baptist Cancer Institute Cervical Cancer: Staging

58

70

53

60

43

50 40

10 8

10

8

10 11 8

13 15 16

20

13 12

20

30

1

Percent

34

0 0

1

2

3

4

Unknown

Stage Baptist 2013

Baptist 2002 - 2011

U.S. Data 2002 - 2011

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Baptist Cancer Institute 2014 ANNUAL REPORT

development of this malignancy. Other risk factors

20 percent of cases are diagnosed in women over

including tobacco abuse correlate with the incidence

age 65. Most commonly, cervical cancers are

of cervical cancer.

diagnosed at an early stage. Among the 24 patients treated last year at Baptist, 75 percent were

Many years ago, cervical cancer was one of the

Caucasian and 21 percent were African-American.

leading causes of cancer death for women in the U.S.

Similar statistics are seen in the 156 patients seen

Over the last four decades, however, there has been

between 2002 and 2011. These percentages reflect

a dramatic reduction in the death rate from this

our community population and are limited by a small

malignancy. This drop is primarily due to effective

sample size. (Figure 18)

screening with the Pap smear. It is important to note, however, that across the globe cervical cancer

The prognosis of a patient with cervical cancer will

continues to be a major health problem with an

depend upon several factors. Most importantly, the

estimated 528,000 cases diagnosed and 266,000

prognosis will depend upon the patient’s stage at the

deaths annually. This is especially true in less

time of diagnosis. Lymph nodal involvement is not

developed nations. For example, in Middle Africa

part of the FIGO staging system but is incorporated

cervical cancer is the most common cancer in women

into the AJCC system. Nevertheless, oncologists

and the incidence is five times higher than in North

agree that involvement of the lymph nodes will

America.

impact a patient’s expected outcome. Other factors that need to be considered are the patient’s overall

In the U.S., cervical cancer has the highest incidence

health, immune status, tobacco use and compliance

among Hispanics, followed by African-Americans

with treatment recommendations, to name a few.

followed by Caucasian women. Women of Asian descent have the lowest risk. Florida has one of the highest rates of cervical cancer in the U.S. The median age of diagnosis is 49 years, but more than

35

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TUMOR REVIEW: CERVICAL CANCER

70

64

80

75 76

Figure 18 Baptist Cancer Institute Cervical Cancer: Race

60 50 40 30

21

Percent

20

7 6

13

16 16

4

10

1

36

0

Caucasian

African-American

Hispanic

Other

Stage Baptist 2013

Baptist 2002 - 2011

U.S. Data 2002 - 2011

Treatment

have been shown to be most effective. In the setting

The treatment recommendations for cervical cancer

of recurrent disease, a combination of treatments will

vary based upon the stage of disease and the health

be employed, partially depending upon what

of the patient. In the earliest stages such as pre-

therapies have already been performed. Within the

invasive or stage IA, uterine sparing surgeries may be

Baptist Health System last year, 38 percent were

sufficient. These patients may be able to retain

treated with surgery alone. In the previous 10-year

fertility, if desired. When the tumor is more advanced,

interval, 45 percent of patients were treated with

but limited to the cervix, the patient will require a

surgery alone. (Figure 19) This rate of definitive

radical hysterectomy or definitive radiation therapy.

surgery is higher than what is seen on a national

Once the tumor has spread beyond the cervix, a

scale, but is likely due to the large number of

combination of chemotherapy and radiation therapy

patients seen at Baptist with Stage I disease.

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Baptist Cancer Institute 2014 ANNUAL REPORT

50

45

Figure 19 Baptist Cancer Institute Cervical Cancer: Treatment

30

30

21

25 20

6

8 5 3

Surgery & Radiation

8

13

13 6 4

Radiation Only

6

7

5

4

10

8

10

15

0

17

17

Percent

35

33

40

38

45

Surgery Only

Radiation & Chemo

Surgery, Radiation & Chemo

Other

No Treatment

Stage Baptist 2013

Baptist 2002 - 2011

U.S. Data 2002 - 2011

Results

in the Baptist Health System is not shown due to

In order to review the survival rate we must analyze

an insufficient number of deaths among patients

data from patients that were treated years ago.

seen in our system.

Due to advances in treatment, these numbers may not accurately reflect the expected survival of a

Future Directions

patient seen in clinic today. The survival rate is best

As mentioned above, screening programs with Pap

for patients with disease treated in the earliest stages

smear utilization have already made dramatic impacts

and worsens as the stage at presentation increases.

in the management of cervical cancer. These

The stage-related survival rate for patients treated

screening programs have allowed physicians to

in the U.S. between 2003 and 2006 is shown.

diagnose the disease at earlier stages. This, in turn,

(Figure 20) The survival rate for patients treated

has resulted in thousands of saved lives.

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TUMOR REVIEW: CERVICAL CANCER

On the other hand, there remains a need for

burden at the time of diagnosis. This will lead to

improvement. Advances in functional imaging, such

optimal individualized treatment plans. New

as PET scanning, are enabling physicians to have a

chemotherapies and biologic agents are being

more accurate assessment of a patient’s disease

evaluated in the clinical setting. Advances in

Figure 2003 - 2006) Figure 220 0 Survival Survival Rates RatesOver OverFive FiveYears Years(Cases (CasesDiagnosed Diagnosed 2003 - 2006) 100 95 90 85 80 75

Cum ula tive Su r vival Rates

38

70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 0.0

1.0

2.0

3.0

4.0

5.0

Years f rom Diagnosis Stage 0

Stage I

Sta

Stage II

Stage III

Sta

Stage IV

Stag

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Baptist Cancer Institute 2014 ANNUAL REPORT

surgical techniques and radiation delivery are

Baptist Health remains committed to the fight against

accounting for safer treatment with reductions in

cervical cancer. In 2013, Southeast Gynecological

the likelihood of a treatment complication.

Oncology Associates became a part of the Baptist Health network. This year, Baptist Health acquired its

One of the most exciting advances is development

own radiation oncology service. With both of these

of vaccines against the HPV virus. These vaccines

services aligned under the same entity, Baptist Health

have been approved by the FDA since 2006 and

believes that a coordinated team has now been

are commercially available. It is hoped that, in time,

assembled to fight gynecologic malignancies in this

these vaccines will lead to a dramatic reduction and

community. This integration of specialized services

possible elimination of this cancer, much like the

will deliver comprehensive, cutting-edge and

eradication of polio in the U.S. At present, it is

compassionate care to improve the lives of those

recommended that pre-teen children undergo this

patients afflicted by cervical cancer. This is one

vaccination, but parents should discuss the pros and

example of how Baptist Health is changing

cons with their child’s pediatrician for specific

health care for good.

guidelines.

39

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QUALITY ASSURANCE

QUALITY ASSURANCE Troy H. Guthrie Jr., MD, MEDICAL DIRECTOR, EDUCATION AND RESEARCH, BAPTIST CANCER INSTITUTE Melissa McCarthan, RHIT, CTR Each year, it is required by the Commission on Cancer and the American College of Surgeons that 10 percent of tumor registry analytic cases be reviewed by physician volunteers to assure that the accuracy and timeliness of the data entered is correct. In the coming years, this percentage will increase to 15 percent. In addition, each year, a retrospective assessment of the quality of data for a tumor site is required.

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Baptist Cancer Institute 2014 ANNUAL REPORT

This year’s quality assessment project will be

since the dismal prognosis of these patients and

pancreatic cancer which was also a site reviewed

the known lack of therapy throughout the U.S. is

retrospectively by Dr. Guthrie within this annual

well recognized by all cancer specialists.

report. The annual review of data is for the years

• Kaplan Meyer survival curves were calculated for

2008 through 2013. During this time, 176 cases were

each stage, at least for Stage I and II, and appear

accrued. The data was reviewed for accuracy of

accurate. Again, as stated under bullets two and

diagnosis, gender, stage, race, treatment and

three survival is felt to be skewed upward since

outcome.

long-term survival by National SEER Registry Data for advanced pancreatic cancer is only about five

The findings of this analysis are as follows:

to 10 percent at five years and less than three

• Pathology was correct in all 176 cases.

percent at 10 years.

• Survival appears to be correct, at least, in the earlystage cases; although late-stage cases lack

Goals from this analysis should include:

adequate follow-up based on my review of the

• To increase the identification of patients that have

individual cases. In Stage III and Stage IV, survival

actually died, particularly if they are listed as being

follow-up tended to be inadequate including

survivors but only have one to two months follow-

patients listed as being alive but having only a very

up. This would improve our comparison to national

short follow-up. For example, 14 out of the 25

data in which, at best, only five or 10 percent of

patients listed as being alive with Stage III or IV

patients will be long-term survivors.

had only one or two months follow-up and are suspected dead rather than being alive.

• Likewise, as in past years, follow-up is questionable since of these 25 Stage III and IV patients only six had follow-ups more than six months. Again,

• To hopefully develop methods so that earlier diagnosis of pancreatic cancers seen at Baptist Cancer Institute will be made thus lowering the high incidence of advanced cases.

• To increase the accuracy of our staging data since

suggesting an inadequate accounting for patients

a large number of patients are listed as Stage II

who are dead instead of being alive. It is felt

and also Stage Unknown, which probably

unlikely that cases are being lost to outside referral

represents patients who died early or patients who

41

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42

QUALITY ASSURANCE

were just lost to follow-up as they moved to

patients. This includes such groups as the BRCA1

palliative care programs.

and BRCA2 breast cancer syndrome, Cowden

• To hopefully counsel patients of genetic risk for

Syndrome, Lynch Syndrome and other genetically

pancreatic cancer, so that increased surveillance

driven cancer syndromes, which have increased

would at least potentially benefit this segment of

rates of pancreatic adenocarcinomas.

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Baptist Cancer Institute 2014 ANNUAL REPORT

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CLINICAL RESEARCH AND EDUCATION

CLINICAL RESEARCH AND EDUCATION In 2013, cancer research for the Baptist Cancer Institute had an upswing that resulted in 90 patients being placed on cancer treatment trials for both Baptist Medical Center Jacksonville and Baptist Medical Center South.

These patients were distributed between Baptist Cancer Institute, Florida Radiation Oncology Group and Cancer Specialists of Northeast Florida. At any one time, approximately 40-50 research protocols were open for consideration of patients with diverse cancer sites including breast, lung, gastrointestinal, melanoma and hematologic malignancies. Protocols were available for a patient to be involved in both treatment as well as registry trials at Baptist Jacksonville and Baptist South. Patients accrued on clinical trials were mostly from the metropolitan area, but patients from other areas, including southeast Georgia as well as more distant locations in Florida, were likewise accrued. Studies were available to patients from both national cooperative groups, including the National Surgical Adjuvant Breast and Bowel Project (NSABP), Eastern Cooperative Oncology

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Baptist Cancer Institute 2014 ANNUAL REPORT

Group (ECOG), North Central Cancer Treatment

kinase inhibitor targeting various lymphoma subtypes,

Group (NCCTG) and Radiation Therapy Oncology

and numerous immunotherapy trials in melanoma

Group (RTOG), as well as studies sponsored through

highlight the high level of protocols offered at Baptist

pharmaceutical companies and private research

Medical Center. Registry trials including the SystHERs

organizations (PRO). At any one time, approximately

trial in HER2+ breast cancer continued as well as

30 percent of the studies were through National

studies in chronic myelocytic leukemia and

Cancer Institute (NCI) sponsored cooperative groups

paroxysmal nocturnal hemoglobinuria. Other registry

and 70 percent were industry-sponsored

trials were opened in metastatic colorectal cancer

pharmaceutical studies. This trend of going to

through the National Surgical Adjuvant Breast and

industry trials reflects a nationwide trend as the NCI

Bowel Project (NSABP). The 2013 patient accrual for

study groups continue to lose funding and ability to

all participants reached 60 patients compared to the

conduct large trials.

previous of 42 in 2012 and 35 in 2011 (Figure 21).

Hopefully, this upswing in patient accrual will continue

All studies done on campus, both NCI-sponsored or

through 2014 and beyond. Again, accrual throughout

pharmaceutical-sponsored, were reviewed by the

the campus remains below the average of 100-plus

Baptist Medical Institutional Review Board (IRB) for

patients seen in the years before 2008. The alliance

appropriateness of research, conflict of interest and

between Baptist Health and MD Anderson Cancer

protection of human rights. All studies were then

Institute, beginning in 2015, will hopefully increase

described in language understandable to the public

accrual for patients as well as the number of studies

in an informed consent and also published on the

ultimately available for patient participation. Accrual

Baptist Cancer Institute website. Studies done in 2013

to patients throughout the nation has been down

included Phase I, Phase II, Phase III, as well as registry

during the last five years due to many diverse reasons

studies. In 2013, studies done at the Baptist Cancer

including pressure on physicians to increase patient

Institute helped lead to FDA approval of Keytruda, a

volume, increasing complexity of insurance and third-

monoclonal antibody against the PD-1 receptor for

party payment for patient participation, as well as

treatment of refractory metastatic melanoma. Other

reluctance of patients to participate in studies that

innovative studies included Phase I studies of a tumor

may cause economic pressure to them.

vaccine in refractory patients with breast cancer as well as a new monoclonal antibody for triple-negative

Baptist Cancer Institute continues to be active as a

breast cancer. Studies of innovative tyrosine kinase

community cancer center offering educational

inhibitors were opened in non-small cell lung cancer

programs giving CME to both physicians and nurses

targeting the RET gene, as well as a spleen tyrosine

through the multi-specialists breast cancer

45

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CLINICAL RESEARCH AND EDUCATION

conferences, neuro-oncology conferences, lung cancer

Fi g u re 2 1 Clinical Research BCI: 2009 - 2013

groups.

In summary, the Baptist Cancer program continues to offer exciting clinical protocols through both cooperative and pharmaceutical companies focusing on cutting-edge immunotherapy and targeted protocols. Likewise, Baptist Cancer Institute offers a wide variety of educational experiences for the physician staff at Baptist Health through teleconference for the broad spectrum of cancer sites as well as conferences given throughout the year.

A great deal of enthusiasm continues on campus for increasing patient accrual and increasing the relevance of clinical trials to every day treatment.

40

42

the research program of NSABP and RTOG study

60

35

at Baptist Medical Center as well as those involved in

80

65

lists the active participants in the cooperative groups

100

90

subjects of the annual tumor board for 2014. Figure 23

90

conferences, as well as tumor board. Figure 22 lists the No . of Patients

46

20 0

2009 2010

2011 2012 2013

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Figure 22

Figure 23

TUMOR BOARD 2014

COOPERATIVE GROUP TRAILS (BCI)

Metastatic Colon Cancer Treatment Approaches, 1/9/14

Dimitrios Agaliotis, MD, PhD – Medical Oncology

The Management of Anal Cancer, 2/4/14

Jeff Bubis, DO – Medical Oncology

An Unusual Case of Large B-Cell NHL, 2/20/14

Stephen Buckley, MD – Gynecologic Oncology

Examples From My Rapidly Changing Cancer

Catherine Bush, RN, OCN, BSN – Study Coordinator

World, 3/16/14 Multiple Myeloma or a Myeloid? Does It Really Matter?, 4/10/14, Troy Guthrie, MD Management of Prostate Cancer, 5/8/14 A Bevy of Active Lymphoma Cases, 5/15/14, Troy Guthrie, MD Some Issues in Colorectal Cancer, 6/12/14, Dimitrios Agaliotis The Effect of Margin Status on Breast Cancer

Andrea Canto – Study Coordinator Carlos Castillo, MD – Medical Oncology Roxane Green – Regulatory Coordinator Troy Guthrie, MD – Principal Investigator, ECOG, NSABP, Mayo Trials Group Zhen Hou, MD, PhD – Medical Oncology Douglas W. Johnson, MD – Sub-Investigator, Radiation Oncology Robert A. Joyce, MD – Medical Oncology

Recurrence: New Consensus Guidelines for an

Mohammad Khan, MD – Medical Oncology

Age-Old Question, 6/19/14, Cynthia Anderson, MD

Mathew Luke, MD – Medical Oncology

Leptomeningeal Metastases: Diagnosis & Treatment, 7/17/14, Troy Guthrie, MD

Alan Marks, MD – Medical Oncology Joseph Mignone, MD – Medical Oncology

Acute Myelocytic Leukemia, 9/11/14, Troy Guthrie, MD

Yuval Naot, MD – Medical Oncology

The Role of Whole Brain Radiation Therapy After

Jeanine Richmond, RN, BSN, OCN, - Study

Stereotactic Radiosurgery for Brain Metastases, 10/2/14, Cynthia Anderson, MD Management of Pancreatic Cysts, 10/30/14, Jose Nieto, MD Interesting Head & Neck Cases, 11/13/14, Troy Guthrie, MD Uterine Leiomyosarcoma, Paul Nowicki, MD

Coordinator Matthew Robertson, MD - Gynecologic Oncology Mila Shteyn, MA - Study Coordinator Unni Thomas, MD – Medical Oncology Maria Valente – Medical Oncology

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CLINICAL RESEARCH AND EDUCATION

Figure 23 (cont’d.)

CANCER RISK ASSESSMENT AND GENETICS Melinda Fawbush, ARNP, MSN Troy Guthrie, MD – Principal Investigator

RTOG Cynthia Anderson, MD – Radiation Oncology

Linda Sylvester, MD – Medical Oncology

Mark Augspurger, MD – Radiation Oncology

Mitchell Terk, MD – Radiation Oncology

Jessica Bahari, MD – Radiation Oncology

Carlos Vargas, MD – Radiation Oncology

Abhijit V. Deshmukh, MD – Radiation Oncology

John Wells, MD – Radiation Oncology

Kenneth Goldstein, MD – Medical Oncology

Larry Wilf, MD – Nuclear Medicine Radiologist

Troy Guthrie, MD – Medical Oncology

Michal Wolski, MD – Radiation Oncology

Douglas W. Johnson, MD – Principal Investigator Anand Kuruvilla, MD – Radiation Oncology Carla Malott, RN – Clinical Research Associate Thomas Marsland, MD – Medical Oncology Lois Morgan, RN – Clinical Research Associate Michael Olson, MD – Radiation Oncology Niraj Pahlajani, MD – Radiation Oncology Shyam Paryani, MD – Radiation Oncology Jan Peer, CCRP – Clinical Research Associate Sonya Schoeppel, MD – Radiation Oncology Neenad Sha, MD – Radiation Oncology Dwelvin Simmons, MD – Radiation Oncology Robert Still, MD – Surgeon J. Wynn Sullivan, MD – Medical Oncology

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SPOTLIGHT IN CANCER CARE

SPOTLIGHT IN CANCER CARE: MARK AUGSPURGER, MD Mark Augspurger, MD, arrived at Baptist Medical Center Jacksonville in 2003.

Dr. Augspurger obtained his medical degree from the University of Florida, Gainesville in 1992 and completed his residency in radiation oncology in the Department of Radiation Oncology at Baylor Medical School in June 2000.

Following completion of his radiation oncology residency he fulfilled military service obligations by serving as a Major in the United States Air Force at Keesler Medical Center, Keesler Air Force Base, Biloxi, Mississippi. He was a staff radiation oncologist at Keesler from August 2000 to April 2002 and became Chief of Radiation Oncology in April 2002 remaining there until June 2003. At that time, he was recruited by Florida Radiation Oncology Group to

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serve as a radiation oncologist for Baptist Health,

closely with the gynecologic oncologists within the

which he has done from July 2003 through April 2014.

field of female genital cancers. Dr. Augspurger’s

In May 2014, he joined Baptist Radiation Oncology

opinion is widely sought in the management of

group.

difficult cases within the radiation oncology field.

His initial clinical activities were at Baptist Medical

Dr. Augspurger is board-certified by the American

Center Jacksonville within the Baptist Cancer

Board of Radiology within his specialty of Radiation

Institute, but when Baptist South opened in 2005,

Oncology since May 2000. He has recertified and

he moved to become the Director of Radiation

maintained his credentials within the American

Oncology at Baptist South, which he has done

College of Radiology. Dr. Augspurger is a member

through the present time. Since arriving at Baptist

of the American Cancer Society, American Medical

Health, Dr. Augspurger has served on the American

Association, American College of Radiology,

Cancer Society Duval Unit, both on various

American Society for Therapeutic Radiation, as well

sponsorship committees as well as being a member

as the Florida Association of Clinical Oncology.

of the Board of Directors from 2005 through 2009.

Dr. Augspurger has been active in multiple

On a personal note, Dr. Augspurger enjoys family life.

committees both at Baptist Jacksonville and Baptist

He has two boys, one age 14 and one age 12, with

South. These include the Baptist Health Foundation

whom he participates in boy scouting activities. He

where he has been a committee member since 2005

and his family enjoy outdoor activities including

to 2014. He has also been on the Credentials

camping, fishing and beach activities, as he states,

Committee at Baptist South from 2005 to 2006 and

“all the activities that Florida has to offer.”

was Secretary of the Medical Staff at Baptist South in 2009. In 2010, he assumed the role of the American

For the Annual Report of 2014, we salute Dr.

College of Surgeons Cancer Liaison Physician for

Augspurger for his dedication to the patients he so

Baptist Health and has continued in this demanding

carefully guides through their multidisciplinary cancer

role to the present. Dr. Augspurger is recognized as

care as well as the work he puts in as the Liaison

a regional expert in radiation oncology particularly in

Physician for the American College of Surgeons

the areas of multidisciplinary care of breast cancer,

helping keep Baptist Cancer Institute an accredited

lung cancer, and head and neck cancer. He is likewise

community cancer center.

known for his multidisciplinary approach working

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