Flmd october 2015

OCTOBER 2015 • COVERING THE I-4 CORRIDOR

UF Health Cancer CenterOrlando Health Proton Therapy and Ongoing Study to Advance Cancer Treatment

A CAUSE WORTH

FIGHTING FOR UNITE AGAINST

BREAST CANCER

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FLORIDA MD - OCTOBER 2015 1

FROM THE PUBLISHER It is my pleasure to bring you another issue of FloridaMD. The upcoming holidays are supposed to be one of happy times spent with family. Unfortunately, for some women and children in central Florida, home life is anything but happy. They suffer an existence fraught with domestic violence and mental and/or sexual abuse. October is Domestic Violence Awareness Month (DVAM).

Accordingly, I have asked Harbor House of Central Florida to inform us about some of the programs they have and some of the services they offer that bring healing and hope, to women and children who are trapped in abusive relationships or have suffered physical trauma. If you suspect that one of your patients may be a victim, please pass along the information discussed below. I hope you will join me in supporting Harbor House and the good work that they do to save women’s lives.

All the best,

Donald B. Rauhofer Publisher

COMING UP NEXT MONTH: The cover will be about the brand new Florida Hospital for Women. Editorial focus is on Urology and Geriatric Medicine.

One-in-four women across the U.S. will experience domestic abuse during their lifetime. You’ve most likely have examined a number of the cases or even know of someone who’s been through it. Harbor House of Central Florida, Orange County’s only state-certified domestic abuse organization, works tirelessly to fight this global epidemic.

Its doors opened in 1976 as a safe haven for survivors of domestic abuse and has evolved into one of the most comprehensive domestic abuse organizations in the country. It is also considered a national leader in domestic abuse intervention, awareness and prevention.

Harbor House seeks to eliminate domestic abuse by providing safety, shelter, counseling, education, advocacy and justice. In addition to a 110-bed emergency shelter operated 24 hours-a-day, it has expanded to provide children’s services, community outreach, legal advocacy services and community and professional education. Last year, Harbor House helped more than 9,000 survivors through the hotline, shelter and advocacy services; and reached an additional 24,000 people through education and outreach events.

They’re also one-of-seven domestic abuse centers in Florida that has a kennel on campus, which has been the transition home to nearly 125 animals of any kind.

Harbor House also developed an app specific to the medical professional called – R3 App (Recognize, Respond & Refer). This is the first app to have information that aids hospitals, doctors’ offices and clinics to make appropriate assessments of domestic abuse survivors and refer them to the proper resources. No other tool is geared towards both healthcare professionals and those at-risk.

It’s currently being upgraded to include the same information, and globally through a partnership with United Nations Women.

October is Domestic Violence Awareness Month. Join Harbor House and take a “no tolerance” stance. Visit harborhousefl.com to learn more about the activities taking place.

For more information and to get involved by donating financially, volunteering or providing wish list items, visit harborhousefl. com, call 407-886-2244 (main office) or email admin@harborhousefl.com. Confidential crisis hotline 407-886-2856.

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Publisher: Donald Rauhofer Photographer: Donald Rauhofer / Florida MD Contributing Writers: Heidi Ketler, Sajid Hafeez, MD, Daniel T. Layish, MD, Olga Ivanov, MD, Amber Orman, MD, Rebecca Moroose MD, Ryan Bisson, MS, CGC, Deborah Nosotti ARNP, Jennifer Thompson, Jeff Holt, Justin Marshall, Esq, Marni Jameson, Corey Gehrold Art Director/Designer: Ana Espinosa Florida MD is published by Sea Notes Media,LLC, P.O. Box 621856, Oviedo, FL 32762. Call (407) 417-7400 for more information.

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contents 4

OCTOBER 2015 COVERING THE I-4 CORRIDOR

 COVER STORY

The UF Health Cancer Center-Orlando Health took a quantum leap forward for cancer treatment in Central Florida when it embraced plans to bring the first proton beam therapy center to the region.

PHOTO: PROVIDED BY ORLANDO HEALTH

It’s been nine years since initial discussions with the world’s first compact proton therapy vendor Mevion Medical Systems, Inc. (Littleton, Mass.) and a year after the delivery of the Mevion S250 superconducting synchrocyclotron proton accelerator. The system is currently undergoing pre-clinical commissioning, and sights are set to begin treatment in the spring of 2016.

The UF Health Cancer Center-Orlando Health proton therapy system is one of only 35 in the world and 15 in the United States, three of which are in Florida. When in full operation, the Proton Therapy Center is expected to draw patients from throughout Florida and the southeastern United States and treat on average 25 patients per day.

ON THE COVER: The UF Health Cancer Center-Orlando Health

PHOTO: PROVIDED BY ORLANDO HEALTH

16 CANCER GENETICS AND IMPLICATIONS OF TESTING 18 COST-SAVINGS PROGRAM HELPS INDEPENDENT DOCTORS -- MCKESSON AND AID PARTNER TO FORM AIDSAVE 21 NUTRITION AND CANCER: IS LOSING WEIGHT DURING TREATMENT A BAD THING?

DEPARTMENTS 2

FROM THE PUBLISHER

8

PULMONARY & SLEEP DISORDERS

9 CANCER 11 BEHAVIORAL HEALTH

13 HEALTHCARE LAW 14 MARKETING YOUR PRACTICE 15 ORTHOPAEDIC UPDATE 19 HEALTHCARE BANKING, FINANCE AND WEALTH

FLORIDA MD - OCTOBER 2015 3

COVER STORY

UF Health Cancer Center-Orlando Health

Proton Therapy and Ongoing Study to Advance Cancer Treatment

By Heidi Ketler team leader for the Breast Care Specialty Center and the Gastrointestinal Clinic. “Because of the dosimetric advantages of proton therapy, it’s a fanIt’s been nine years since initial discussions with the world’s tastic treatment modality to first compact proton therapy vendor Mevion Medical Systems, bring to Orlando Health and Inc. (Littleton, Mass.) and a year after the delivery of the Mevion patients in Central Florida.”

S250 superconducting synchrocyclotron proton accelerator. The Cancer patients are genersystem is currently undergoing pre-clinical commissioning, and ally treated with traditional sights are set to begin treatment in the spring of 2016. radiation modalities (photons, The UF Health Cancer Center-Orlando Health proton therapy gamma rays and electrons), system is one of only 35 in the world and 15 in the United States, chemotherapy or surgery – or Daniel Buchholz, MD three of which are in Florida. When in full operation, the Proton a combination of the three.

Therapy Center is expected to draw patients from throughout Proton therapy beam radiation is a type of particle beam radiaFlorida and the southeastern United States and treat on average tion that is optimized for treating deep-seated tumors with the 25 patients per day. least amount of dose contribution to surrounding healthy tis“It’s been a big and exciting endeavor for us,” says radiation onsue compared to all other types of radiation modalities. Proton cologist Daniel J. Buchholz, M.D., F.A.C.P., Chairman of radiatherapy deposits focused radiation dose in a sharp peak within tion oncology for UF Health Cancer Center-Orlando Health and the tumor, and little or no dose is delivered beyond the tumor, thereby reducing dose to adjacent healthy tissue.

Members of the UF Health Cancer Center team pose with the MEVION S250 The UF Health Cancer Center-Orlando Health took a quantum leap forward for cancer treatment in Central Florida when it embraced plans to bring the first proton beam therapy center to the region.

superconducting synchrocyclotron proton accelerator on November 2, 2015 before it was lifted and placed inside the Proton Therapy Center.Front row, from left, Naren Ramakrishna, MD, PhD; Daniel Buchholz, MD; Omar Zeidan, PhD; Veronica Schimp, DO. Back row, from left, Sanford Meeks, PhD; Clarence Brown, MD; Justin Rineer, MD; Tomas Dvorak, MD.

Theoretically, less radiation outside of the treatment area reduces the side-effect risk of traditional X-ray therapy. Minimizing side effects is a priority for every cancer patient, especially children. While traditional radiation is an important tool in treating pediatric cancer, there are side effects that can impact growth and development, neurocognitive function, hormonal function, hearing and the risk of radiation-induced cancers. Proton therapy can decrease the risk of many of these potential adverse effects.

Currently, protons are used to treat a variety of tumors including brain and spine, lung, prostate, gastrointestinal, breast and head and neck.

SATISFYING A NEED PHOTO: PROVIDED BY ORLANDO HEALTH

Cancer is on the rise in the Sunshine State.

According to the American Cancer Society’s Cancer Facts and Figures 2015 publication, Florida ranks second highest in estimated number of new cancer cases, excluding basal cell and squamous cell skin cancers and in situ carcinomas except urinary bladder.

“Because of our region’s cancer burden, due in large part to an aging population, the addition of the proton therapy center to our treatment arsenal is a big deal. Innovative strategies for 4 FLORIDA MD - OCTOBER 2015

COVER STORY meeting the growing demand for cancer treatment and care is needed,” says surgeon Mark Roh, M.D., M.M.M., F.A.C.S., president of UF Health Cancer Center-Orlando Health, who also serves as the chairman of the department of surgery.

More proton therapy centers are opening across the country, because the technology has advanced to significantly reduce the complexity, size and cost that are associated with constructing and operating these centers.

PHOTO: PROVIDED BY ORLANDO HEALTH

“Bringing proton therapy to Orlando Health has been a big investment in improving the health of the region and a complex process,” Dr. Roh says.

“We are committed to providing the best possible care for each patient who walks through our doors.”

The synchrocyclotron proton accelerator weighing 58 tons is lifted from a flatbed truck by a 600-ton crane and carefully placed into the proton center’s vault through a hatch in the ceiling.

(November 2, 2014)

This trend will help shorten the travel distance for many patients and family members, who must leave home for daily treatments that last up to five to six weeks. “This is especially difficult for pediatric patients and their parents,” says Dr. Roh.

Mark Roh, MD

Naren Ramakrishna, MD, PhD

“Rather than going far to get the best treatment, we are going to have a facility here in Orlando, where pediatric patients will be the first priority for this treatment. Equally exciting over time, is that we will be expanding the types of patients and cancers we are going to be treating,” says Naren R. Ramakrishna, M.D., Ph.D., who is Director of Proton Therapy and Neurologic and Pediatric Radiation Oncology and Co-director of the Brain and Spine Tumor Program for UF Health Cancer Center-Orlando Health.

JOINING THE REVOLUTION “Proton therapy has only been feasible for centers of our size within the last five to six years, due to the advent of more compact proton therapy systems. Before then, proton therapy was restricted to a few, very large centers,” says Dr. Ramakrishna. The

cyclotrons that produced the proton beam in traditional proton centers cost upwards of $150 million and typically occupied the footprint of a football field.

The proton system at Orlando Health costs nearly $25 million and occupies a fraction of the footprint (16,000 square feet) compared to large-capacity multi-room proton centers. In addition, it requires less staff to operate. This relatively small footprint allowed for annexing the proton center building to the existing UF Health Cancer Center building, which will provide seamless access to radiation oncology patients to proton therapy and other hospital-based services.

“The technology that made a compact proton therapy system possible, relied on major advances in the design of synchrocyclotrons which utilize superconducting magnets to accelerate protons,” says Dr. Ramakrishna.

The compact Mevion system is housed in the 16,000-squarefoot Proton Therapy Center. The facility has three floors – two above ground and one underground – to accommodate the revolutionary proton accelerator system design. The walls are 10 feet thick.

The proton treatment facility also is far less intimidating, with a procedure room that is well lit and designed for comfort. The synchrocyclotron, a type particle accelerator that can produce high energy proton beams, is behind sound-buffering walls, minimizing distracting noise. All the patient sees is the treatment table and the treatment delivery nozzle.

Omar Zeidan, Ph.D., who serves as the Chief of Proton Therapy Physics, has been overseeing the installation of the Mevion system since its arrival. Previously, he was the Director of Proton Therapy Physics at the ProCure Proton Therapy Center in Oklahoma City, Okla. His team currently includes two physicists and two dosimetrists with additional staff members expected to FLORIDA MD - OCTOBER 2015

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COVER STORY be hired during the next few months leading to the clinical go-live date in April 2016. His team works closely with Dr. Ramakrishna and other radiation oncologists on all of the preparation aspects for implementing clinical proton treatments.

ADVANCING PROTON BEAM THERAPY

PHOTO: MEVION MEDICAL SYSTEMS

In a few months, the proton system will be released by the Mevion technicians for final clinical testing. In the meantime, the radiation oncology team is simulating patient treatment.

“We are running proton treatment simulation plans on all types of diseases and creating a thorough approach to evaluating best practices for each disease site,” says Dr. Ramakrishna.

A rendering of the inside look at the assembled proton therapy accelerator machine.

As a member of an elite group of centers offering proton therapy, UF Health Cancer Center-Orlando Health intends to be actively involved in advancing the knowledge and capabilities of the proton beam radiation technology.

reduce this risk,” says Dr. Roh.

“Orlando Health has committed to helping us deliver the best and most up-to-date treatment for our patients. As early adopters of the technology, the onus is on us to prove through research situations where proton therapies are significantly better than standard treatment,” says Dr. Buchholz.

Dr. Ramakrishna calls proton accelerator therapy a 10 on a scale of one to 10, with 10 representing a medical advance of great significance. “With its targeted radiation dose, protons are a major step in the evolution of radiation therapy, offering unique opportunities to further reduce radiation exposure to healthy tissues.”

Proton Therapy Center patients will participate in numerous clinical studies that gather data on proton therapy treatments and outcomes. “It takes years of clinical study, but we are optimistic the studies will demonstrate the theoretical advantage of proton beam treatment,” says Dr. Ramakrishna.

“Proton beam therapy is not for every patient, but there is a select and growing number of patients as ongoing research reveals greater treatment potential,” says Dr. Roh.

Even though proton therapy has been in existence since 1954 – with the first clinical treatments performed at the Berkeley Radiation Laboratory and at the Harvard Cyclotron Laboratory in A rendering of the side view of the three-story Proton Therapy Center.

“Because access to proton therapy has been limited over the years, the amount of long-term data that we have on treatment outcomes with common cancers, such as breast, lung, prostate cancer, is quite limited,” says Dr. Ramakrishna.

Currently, there is significant interest in evaluating the benefits of treating cancer in the left breast. In these cancer patients, “the traditional radiation scatter effect has been found to affect the heart, producing late effects on cardiac function years down the road. The precise nature of proton beam radiation therapy could 6 FLORIDA MD - OCTOBER 2015

PHOTO: MEVION MEDICAL SYSTEMS

In general terms, he says, proton therapy is equally effective as traditional X-ray treatment but with decreased short- and long-term side effects. In some cases, proton therapy is more effective than X-rays, as the more highly focused dose allows safe delivery of higher doses to tumors. This has been shown to be of benefit for several rare tumors located in the brain and spine (chordoma and chondrosarcoma) or the eye (uveal melanoma).

PHOTO: MEVION MEDICAL SYSTEMS

COVER STORY

A rendering of the patient treatment area for the Proton Therapy Center,

the early 1960s – it is still considered state-of-art,” says Dr. Ramakrishna.

Dr. Ramakrishna likens proton therapy to space program technology, technology that is constantly advancing beyond current possibility. Likewise, the expectation is that proton technology will advance as clinical study demonstrates long-term benefit and expanded indications for its use in fighting cancer.

The cancer center will host an educational symposium for area physicians Nov. 19 and Nov. 20. A panel of invited speakers will present lectures on both the physics and clinical aspects of proton therapy and offer credit for continuing medical education (CME).

REFERRING PATIENTS UF Health Cancer Center-Orlando Health cancer treatment encompasses the full range of options, which soon will include proton therapy.

“Our goal as a radiation oncology center is to be able to offer the most appropriate treatment for our patients,” Dr. Buchholz says. “We will be able to offer proton therapy when it’s most appropriate or standard therapy when it’s the most appropriate.

This will allow us to continue to stay on the forefront of oncology treatment.”

A multidisciplinary team of specialists, including a radiation oncologist and surgeon, will work with the referring physicians to determine the treatment plan that’s best for the patient.

For more information about proton therapy, visit www.orlandohealth.com or www.proton-therapy.org. 

“It’s been a big and exciting endeavor for us.

Because of the dosimetric advantages of proton therapy, it’s a fantastic treatment modality to bring to Orlando Health and patients in Central Florida.” – Daniel J. Buchholz, M.D., F.A.C.P., Chairman of radiation

oncology for UF Health Cancer Center-Orlando Health and team leader for the Breast Care Specialty Center and the Gastrointestinal Clinic

UF HEALTH CANCER CENTER ORLANDO HEALTH PROTON THERAPY CENTER 321.841.1869 and UFHealthCancerOrlando.com.

FLORIDA MD - OCTOBER 2015

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PULMONARY AND SLEEP DISORDERS

Idiopathic Pulmonary Fibrosis – Current Approach to Therapy By Daniel T. Layish, MD Idiopathic pulmonary fibrosis (IPF) is also known as usual interstitial pneumonitis (UIP). There are estimated to be 48,000 new diagnoses of IPF per year in the United States, with 40,000 deaths per year.

About two thirds of patients with IPF pass away within five years of diagnosis. For many years, combination therapy with prednisone and azathioprine had been used. However, the PANTHER trial revealed convincingly that combination therapy with prednisone and Imuran actually resulted in greater mortality, more hospitalizations, and more serious adverse events than placebo. Therefore, combination therapy with azathioprine and prednisone is no longer recommended. For a while, treatment of IPF had been essentially supportive including supplemental oxygen, pulmonary rehabilitation and vaccination against Streptococcus pneumoniae and influenza. Lung transplant can also be considered when appropriate.

Pirfenidone (Esbriet) is an antifibrotic agent, which has now been shown in several clinical trials to reduce disease progression and improve progression free survival in patients with IPF. Pirfenidone inhibits the synthesis of transforming growth factor Beta, which plays a role in cell proliferation and differentiation.

There have been two previous phase III trials of Pirfenidone that seem to have conflicting results. One study (published in 2010) showed that Pirfenidone slows disease progression while another study (published in 2011) did not meet its end point.

However, this last study did have some trends that were in a positive direction; this resulted in the FDA requesting the “ Assessment of Pirfenidone to Confirm Efficacy and Safety in Idiopathic Pulmonary Fibrosis Study” (ASCEND). The result of this study was published in the New England Journal of Medicine. In the ASCEND study, 278 patients with IPF were randomized to receive Pirfenidone 2403 mg per day for 52 weeks. 277 patients were randomized to receive Placebo. The primary endpoint was forced vital capacity and secondary end points included 6-minute walk test distance, progression free survival, dyspnea, overall mortality and disease specific mortality.The proportion of patients who had an absolute reduction of at least 10% in predicted forced vital capacity (FVC) or who died was 47.9% less in the Pirfenidone group as compared to the Placebo group. In addition, the average decrease in FVC from baseline was lower in the Pirfenidone group versus the Placebo group (235 versus 428 mL).

Furthermore, the proportion of patients who had no decline in FVC was 132% higher in the Pirfenidone group than in the Placebo group and there was also less decline in the 6-minute walk distance in the Pirfenidone group compared to the Placebo group as well as better progression free survival. However, there was no significant difference in dyspnea score and all cause mortality or disease specific mortality between the two groups.

There has been a pooled analysis of data from all three Pirfenidone trials, which revealed that the overall risk for death at 52 weeks was lower in the Pirfenidone group versus the placebo 8 FLORIDA MD - OCTOBER 2015

group with a hazard ratio of 0.52. In this pooled analysis Pirfenidone improved both all cause mortality and disease specific mortality. The most common side effects included gastrointestinal and skin related adverse effects, but these rarely led to treatment discontinuation.

Unfortunately, patients on Pirfenidone do not necessarily perceive improvement and Pirfenidone is certainly not a cure for this serious illness. Nevertheless, it appears to be a good option for slowing down the progression of this serious condition.

Another new option for treating UIP/IPF is Nintedanib (OFEV®) This is a tyrosine kinase inhibitor that targets growth factors including the vascular endothelial growth factor receptor, fibroblast growth factor receptor and platelet derived growth factor receptor. In May 2014, Luca Richeldi et al published the results of two 52 week randomized, double blind phase 3 studies of nintedanib (150 mg twice/day) versus placebo in the New England Journal of Medicine. 1066 patients were enrolled in a 3:2 randomization. The adjusted annual rate of change in FVC was negative 115 ml with Nintedanib versus negative 240 ml with placebo. Diarrhea occurred in over 60 percent of patients on Nintedanib but led to discontinuation in less than five percent.

The most frequent serious adverse reactions reported in patients treated with OFEV® (more than placebo), were bronchitis (1.2% vs. 0.8%) and myocardial infarction (1.5% vs. 0.4%).

However, in the predefined category of major adverse cardiovascular events (MACE) including myocardial infarction, fatal events were reported in 0.6% of OFEV® treated patients and 1.8% of placebo-treated patients. Therefore, the clinician must weigh the risk/benefit ratio of using this medication in a patient with known coronary artery disease (or cardiovascular risk factors) carefully.

In conclusion, IPF/UIP is a relatively common and progressive pulmonary disorder. Pirfenidone and Nintedanib are two new agents that appear to slow down the progression of this disease.

Further research needs to be done to identify agents that can reverse pulmonary fibrosis. Since Nintedanib and Pirfenidone seem to have similar efficacy, most clinicians choose one over the other based on side effect profile and dosing considerations.

References available upon request

Daniel Layish, MD, graduated magna cum laude from Boston University Medical School in 1990. He then completed an Internal Medicine Residency at Barnes Hospital (Washington University) in St.Louis, Missouri and a Pulmonary/Critical Care/Sleep Medicine Fellowship at Duke University in Durham, North Carolina. Since 1997, he has been a member of the Central Florida Pulmonary Group in Orlando. He serves as Co-director of the Adult Cystic Fibrosis Program in Orlando. He may be contacted at 407-841-1100 or by visiting www.cfpulmonary.com. 

CANCER

Update on Radiotherapy for Early Stage Breast Cancer Patients – One Dose Radiation Therapy May Control Tumor Recurrence as Effectively As Traditional Radiation Therapy

By Olga Ivanov, MD Dr. Olga Ivanov was among the first breast surgeons in the United States to explore clinical trials surrounding the effectiveness of Intraoperative Ra-diation Therapy (IORT) in patients diagnosed with early stage breast can-cer.

The changes taking place in breast cancer radiotherapy are providing pa-tients with more treatment options. Following a lumpectomy, women have traditionally withstood the time consuming and stressful standard treatment that requires daily radiation to the whole breast for a total of three to six weeks. Consequently, up to one-third of patients compromise their health by failing to complete their radiation treatment plan. Thirty-five to forty per-cent of such patients experienced a reoccurrence of breast cancer.

Intraoperative Radiation Therapy (IORT) addresses the problems related to lack of follow through by administering a single, condensed dose of radia-tion immediately following a lumpectomy.

THE ADVANTAGES OF IORT While the effectiveness of IORT was proven in the TARGIT clinical trial — which showed a similar risk of cancer recurrence

within the breast among women treated with IORT compared to standard breast radiotherapy — the treatment is not right for everyone. I begin by educating my patients on all treatment and care options. If eligible for IORT, patients receive the fol-lowing information on the advantages.

MORE EFFICIENT: Breast cancer patients avoid the need for six to seven weeks of the tradi-tional radiation therapy which means less stress, travel time and missed worked. The side effects of radiotherapy are confined to the tumor bed.

LESS EXPOSURE: IORT delivers less radiation to surrounding healthy organs and tissue, which minimizes exposure to healthy tissue and critical organs including the skin, ribs, and heart. With the standard treatment, radiation must first pass through the breast skin before reaching the inside, as opposed to IORT, where exposure can be avoided by pulling away the skin during the procedure.

A CLOSER LOOK AT THE IORT PROCEDURE STEP ONE: Lymph nodes are immediately biopsied to ensure there is no involvement with cancer. Once a patient is cleared, IORT can be administered.

STEP TWO: The surgeon performs a lumpectomy, leaving a cavity where the tumor was located.

STEP THREE: The radiation oncologist places the Xoft® ballon applicator into lumpectomy cavity to administer the onetime dose of radiation intraoperatively. Reten-tion sutures secure the Xoft® balloon applicator.

STEP FOUR: Radiation is delivered to the surrounding tissue for 9-15 minutes.

STEP FIVE: The Xoft® balloon applicator is removed and the surgeon closes the inci-sion.

CLINICAL TRIALS: THE RESULTS ARE CONSISTENTLY POSITIVE While the introduction of IORT is recent (developed in the 1990s), the early clinical results are encouraging. Studies suggest that the new technique of-fers about the same overall survival rates as whole-breast traditional radia-tion therapy for women diagnosed with early stage breast cancer.

FLORIDA MD - OCTOBER 2015

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CANCER In 2000, originators of a method called targeted intraoperative radiotherapy, or TARGIT, initiated a clinical trial to compare it with traditional radiation therapy. In an article published in the Lancet in February of 2014, the re-searchers calculated that the five-year risk of cancer recurrence was 3.3% for the women who had IORT, compared with 1.3% for the control group—a margin that was within the trial’s predetermined definition of “noninferiority.” The study also revealed that women who had IORT had fewer severe skin problems.

TARGIT-A TRIAL SUMMARY Published in The Lancet, February 2014

MAIN FINDINGS: 1. The risk of recurrence among patients receiving IORT was within the non-inferior margin to those treated with traditional breast radiotherapy.

2. There was no difference in the long term survival between recipients of IORT or standard radiotherapy.

3,451 women from 33 centers in 11 countries, including the United States; ages 45 or older diagnosed with early stage breast cancer (Size: < 3.5 cm) were randomly assigned to have either intraoperative radiation therapy or whole-breast external beam radiation therapy: • 1,721 women got intraoperative radiation therapy. (15.2% of these women had to have additional whole-breast ex-ternal beam radiation therapy after surgery because their pathol-ogy report showed the cancer had more advanced characteris-tics than originally thought.)

• 1,730 women got whole-breast external beam radiation therapy. After 5 years of follow-up, researchers found that both radiation tech-niques had about the same breast cancer survival rates:

Fall Conference & Webcast

on Children’s Grief

What: Where: Date: Time:

Patient testimonial:“The risk seemed negligible and the convenience seemed huge,” she says. “I had this done on a Friday and I was back at work on Monday.”

10 FLORIDA MD - OCTOBER 2015

Local Host:

Featured Presentations SESSION SPONSORS:

Session One: Kenneth J. Doka, PhD Helping Children and Adolescents Cope with Grief and Loss: A Hospice Perspective Session Two: Donna Schuurman, EdD, FT Helping Children, Teens and Families after a Sudden or Unexpected Death Session Three: Harold Ivan Smith, D.Min., FT “OMG! You Actually Took a Child to a Funeral!?”

Re-childing death memorialization in a busy, ritual “lite” multicultural society.

• 98.1% for whole-breast external beam radiation therapy At the Comprehensive Breast Health Center at Celebration Health, potential candidates for breast IORT are women aged 45 or older with a new di-agnosis of early stage breast cancer (a tumor size less than or equal to 3 cm and no positive lymph nodes) who are planning to undergo lumpecto-my.

Register @ www.ChildrenGrieve.org

NAGC Fall Conference & Webcast Rosen Plaza Hotel 9700 International Drive Orlando, FL 32819 Thursday, Nov. 12 Noon – 5:00 pm EST

This half-day conference aims to raise awareness and educate communities about childhood bereavement.

• 97.4% for intraoperative radiation therapy

WHO IS ELIGIBLE FOR IORT?

Olga Ivanov, MD, FACS, is a leader in the field of overall breast health and specialized breast surgery. A board-certified and fellowship-trained breast surgeon, Dr. Ivanov serves as the Medical Director of the Comprehensive Breast Health Center at Celebration Health in Celebration, Florida. She re-ceived her medical degree from the Medical College of Ohio, completed her residency in general surgery at Loyola and, in 2005, completed her breast surgery fellowship training at Northwestern Memorial Hospital. She brings her innovative breast care program to Celebration Health from Chi-cago, Illinois, where she served as Medical Director of the Comprehensive Breast Health Center at Little Company of Mary Hospital. 

Attend the Live Event

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Cost: $85.00 - NAGC members $95.00 - Non-members Plus an additional $25.00 for 4.5 CE’s

Cost: $120.00* - NAGC members $130.00* - Non-members Plus $25.00 per person for 4.5 CE’s

Where:

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Rosen Plaza Hotel Hotel accommodations call 407.996.9700 *Lunch is not included with registration after Nov 6. Registration is open until Nov 12.

Register for CEs by Nov. 6 Registration will remain open until Nov. 12 if CE’s are not required through the NAGC’s CEU sponsor.

BEHAVIORAL HEALTH

Treating the Spirit STORY

By COVER Sajid Hafeez, MD A safe assumption is that when a patient is involuntarily admitted to an acute crisis unit, he or she is probably not having a good day. Even those who are admitted there on a voluntary status are doing so because they see treatment as a last result. They are hopeless. They are helpless. Maybe their meds have stopped working.

Maybe they have lost someone. Maybe they have been arrested.

Maybe depression just slowly snuck up on them. While medication can treat the chemistry, and therapy can teach coping skills, a large part of recovery is treating the spirit.

As any doctor will tell you, a vital part in the patient recovery is the restoration of hope. When a patient can see that there is the potential to return to a state of mental wellness, that patient begins to take an active investment in his or her treatment, which is a great indicator of success. The question is, how exactly does one conjure optimism where none exists?

It starts by first validating the patient. Stigma against mental health runs deep through society, and often times those who struggle with issues compare themselves to people they feel are successful and without problems. The patient must be treated with the dignity and respect due any person, regardless of his or her behavior or condition. In showing common courtesy, understanding, and empathy, it helps the patient to feel like less of a failure or outcast. A trained staff of nurses, therapists, and techs

understand that most people in crisis will act as they do out of fear, the avoidance of pain, or to gain a sense of control over a new and potentially frightening environment. With this understanding it is easier to accept without judging so that together the staff and patient can focus on what can be instead of what is.

A major part of hopelessness is the unknown. The patient is often completely unaware of how to begin the path to wellness.

As such, a second facet of restoring hope is education. In conversation with the doctor, a patient is educated on the causes of his or her affliction, and what medicines can be used to treat it. Each potential plan of treatment or medication acts as an arrow to fill the patient’s quiver. Now unfortunately, some of these may miss the mark. Yet as long as that quiver remains full of different medications, ideas, and approaches, there always exists a chance to hit the bull’s-eye. In this the combined knowledge and optimism of the doctor translate to an optimism for the patient. Hope is amazing in that it can be borrowed by one in need from someone who has excess. This is also emboldened by a trust in the confidence of the doctor’s ability, trustworthiness, and knowledge. As such even if a doctor has doubts, it is vital to focus on the best potential in order to lend out that optimism.

Continued on page 12

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BEHAVIORAL HEALTH Next, it falls upon the techs and the therapists to buff the patient’s self esteem. Through guided existential evaluation, any patient can be walked through a path to discover what it is that he or she likes best about his or her self. In doing so, the staff is effectively breathing life back into a fading ember before it goes out. When that patient begins to recognize that there are aspects of life that they do enjoy, it is possible to fan those embers to glow a little brighter and a little hotter. While the process may not happen all at once, over time, this ember can be rekindled into a small flame of purpose. When a patient is able to regain a sense of purpose, it represents a turning point wherein a patient is able to cross that bridge of hopelessness into hopefulness. The solution to this problem is making the patient feel he or she is the star of his or her own story of recovery, and not just a supporting role. It is then that the patient can draw the connections between what it is that defines hope, and make a promise to his or her self that he or she does have value and that they have a sense of control in the outcome.

Those patients who develop this understanding are those who are most likely to succeed. However, a hospital is a temporary escape from the real world where stressors, and problems often are temporarily placed on hold. It then falls upon the duty of the facility to provide a plan of action at discharge as opposed to releasing the patient with nowhere to go. Patients are then recommended to the next level of care. For some it may be a day program. For others it may simply be a follow-up therapy with med management. What is known is that success rates are shown to be higher when the follow up is carried out as soon as possible. With a plan in hand, a patient has less to fear of the unknown.

As of yet, medical science has made no discoveries of how to put hope and optimism into a pill. Until that time, medical professionals will continue to use the kindness, empathy, and compassion to achieve the same results. Ultimately, when all is said and done these are the best medications that we as health professionals have to offer.

Sajid Hafeez, M.D., is a child and adolescent psychiatrist who is serving as a Medical Director of the Acute Care Baker Act Unit at the University Behavioral Center. He also served as the Center’s Medical Director of the long term Residential Units: ASAPP Unit (for adolescent boys with inappropriate sexual behaviors), Solutions Unit (for adolescent boys with behavior problems), Promises and Stars Unit (for adolescent females with behavioral problems as well as victims of sexual abuse), and Discovery Unit (for children ages 5-13 with behavioral as well as inappropriate sexual problems). In addition, Dr. Hafeez also Served as an Assistant Professor of Psychiatry at the University of Central Florida (Voluntary Position). He was also the Chief of the Adolescent Psychiatry Unit, an Attending Psychiatrist of the Comprehensive Psychiatry Emergency Program and of the Mobile Crisis Team at the Westchester Medical College. At Vassar Brother’s Medical Center in New York. Dr. Hafeez was the Director of Outpatient Child & Adolescent and Adult Psychiatric Clinic as well as Director of Consultation and Liaison Psychiatry. Dr. Hafeez received his adult Psychiatry and Residency Training at the University of Kansas Medical Center in Kansas City. He received his Child and Adolescent Psychiatry fellowship training at the New York Medical College New York and at Children’s National Medical Center of George Washington University in Washington, DC. Dr. Hafeez can be reached at 407-281-7000 or by visiting www. universitybehavioral.com.  12 FLORIDA MD - OCTOBER 2015

HEALTHCARE LAW

Florida Courts Emphasize Provider Relationships in Recent Medical Negligence Cases By Justin Marshall Predicting what a judge will do when presented with a given set of facts is one of the more difficult tasks we face as counsel in medical negligence cases. The ever capricious jury may rightfully get more attention in this respect, but the judge could make dozens of pivotal decisions before a case ever sees a jury. Each of these decisions could drastically alter liability exposure, and could result in anything from barring critical testimony to dismissal of the case.

While the current state of Florida law is difficult to enunciate at any given time, we can identify certain trends from recent appellate decisions that guide our legal analysis of liability even before a lawsuit is filed. One such recent trend in Florida courts has been the significance of relationships between the nursing staff, physicians, and hospitals or other provider entities. Three recent and disparate appellate opinions, each involving dispositive issues at various stages of litigation, serve to illustrate this theme and highlight the importance of defining the parameters of provider relationships from a legal perspective.

CASE 1 – EARLY LITIGATION; NURSING STAFF & PHYSICIAN/HOSPITAL RELATIONSHIP

defendant university, holding it had no legal responsibility for the care and treatment provided by the only physician allegedly associated with the university in the pleadings. The court reached this conclusion despite the plaintiff’s belated attempts to argue the university could have been responsible for the negligence of other physicians at the final hearing.

CASE 3 – POST-VERDICT; RELATIONSHIP BETWEEN PHYSICIANS Cantore v. West Boca Medical Center, Inc., (September 2015) (Not Released)

In Cantore, the Fourth District engaged in a lengthy analysis of prior law holding that a physician cannot insulate him or herself from liability by presenting a subsequent treating physician who testifies that adequate care by the defendant physician would not have altered the subsequent care. Distinguishing these cases in affirming the trial court’s allowance of a non-party, co-treating physician’s testimony at trial under similar circumstances, rather than a subsequent treating physician, the appellate court affirmed judgment in favor of defendant medical center and hospital.

University of South Florida Board of Trustees v. Mann (March 2015)

For more information, call Justin Marshall at 407-843In Mann, the Second District held that the trial court should 8880.  have dismissed the case against one hospital defendant where the Plaintiff’s pre-suit expert affidavit, required to corroborate reasonable grounds for medical negligence per Section 766.203(2), Florida Statutes, was insufficient. While the verified medical opinion arguably identified grounds to proceed against other provider defendants based on the negligence of the treating Do you see patients whose partners physically harm, physician, the affidavit never addressed any insult, threaten or verbally abuse them?

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MARKETING YOUR PRACTICE

10 Tips to Creating Engaging Video Content Without Knowing What You’re Doing

By Jennifer Thompson We know the future of web content is all video. By 2017, video will account for 69 percent of all consumer Internet traffic, according to Cisco. So how can you capitalize on this trend and put your medical practice ahead of the curve?

The best way is to start creating engaging video content today.

Not sure how? Don’t worry, we’ve got you covered.

TIPS FOR CREATING ENGAGING VIDEOS You know how they say a picture is worth a thousand words?

Well, one minute of video is worth 1.8 million words, according to Forrester Research. Kind of a big difference. Oh, and seven in 10 people view brands in a more positive light after watching interesting video content from them, according to Axonn Research.

The key phrase there is “interesting”.

Marketing your practice in a video can be as simple as a patient testimonial or an ask the doctor series answering common health questions. Videos should be educational and/or emotional and contain a message that connects with the viewer quickly.

Here are tips to help your practice create engaging videos: • Connect to patients’ emotions. One of the main drivers of video storytelling is human emotion. Healthcare practices are filled with compelling, human interest stories from patients and staff. Share them. Don’t focus on the procedure side of a testimonial, instead discuss the fact the patient is able to walk again and visit with their grandchildren.

• Consider your patients and potential audience. Ensure the video is going to be relevant to them and that it’s not just something you or your doctors would be interested in. In other words, don’t get too technical and put yourself in the patient’s shoes when planning or asking questions.

• Make professional quality videos. Advances in technology have driven the costs of video production down. A video will represent your brand and you will want viewers to know that your brand is professional. If you don’t have the means or knowledge to make a professional video, hire someone to do it for you. If your videos look amateurish, what does that say about your quality of care?

• Get b-roll for your videos. Even if it’s only two minutes in length, make sure there is plenty of b-roll footage to keep the segment interesting. Staring at someone for two minutes straight is boring (and creepy).

• Have a consistent video structure. Make sure your video has a clear beginning, middle and end. If necessary, create a storyboard ahead of time that describes exactly how your video should be filmed and edited together. Keep this structure on all relevant videos so your videos have a “brand” and “iden14 FLORIDA MD - OCTOBER 2015

tity” that can be felt in each.

• State your video’s purpose. Make sure your viewers know within the first 10 seconds why they should keep watching. Focus on the outcome. Most patients don’t care what it takes to get there, just how long it takes to recover and what they will experience when healed.

• Choose one topic. Focus on one topic per video and delivering that idea well.

• Consider the length. Most viewers will only watch a video for about two minutes. Try to keep videos less than 5 minutes no matter what.

• Share your videos on social media. Promote your video on Facebook, Twitter, in email blasts and on other social media channels your practice engages in. When you promote your video, make it easy for patients to share it.

• Put your video on your website. You worked long and hard to create your masterpiece, so make sure it lives on past your social post. Embed your video on your website so patients can view it indefinitely.

There you have it. Follow these tips and you should be well on your way to creating quality video to attract and retain more patients for your medical practice.

Jennifer Thompson is co-founder and chief strategist for DrMarketingTips.com, a website designed to help medical marketing professionals market their practice easier, faster and better. 

ORTHOPAEDIC UPDATE

Bone Cyst Removal Surgery Helps Patient Reclaim Active Lifestyle By Corey Gehrold When Amber Kellum discovered she had a potentially cancerous bone cyst in her tibia, she was understandably concerned over how the condition would impact her life. Could she continue her active lifestyle? Would she ever be able to walk the same? Luckily, the answer to both questions from her surgeon, Orlando Orthopaedic Center’s Craig P. Jones, M.D., was a resounding, “Yes.” Dr. Jones, a board certified orthopaedic surgeon fellowship trained in orthopaedic oncology, discussed treatment options with Amber; and in order to remove the tumor and get her back on her feet as quickly as possible, she chose to have a rod placed in her tibia once the cyst was removed. A mere six weeks later she was walking again, on her way back to the gym and her job as a server at a busy restaurant. “I was really glad Dr. Jones took care of me because, here I am, back in the gym able to do what I could do before and [I’m] able to live my life.”

WHAT IS BONE CYST REMOVAL SURGERY? Bone cysts are fluid-filled holes that develop inside a bone. Although they can occur at any age, most often they affect children and young adults. Typically, cysts do not present any symptoms; however larger cysts can lead to a bone becoming weak, thereby increasing the likelihood of a fracture (break).

“Though not often, sometimes the bone cyst can progress to a point where it can cause permanent damage to the bone if left unattended,” says Dr. Jones. “With the removal of the cyst and the placement of the rod, as in Amber’s situation, the likelihood of sustained damage in minimized and recovery can begin immediately.”

There are two types of bone cysts that determine the course of action and recovery: A unicameral bone cyst, or simple bone cyst, creates a cavity in the bone that fills with fluid. This typically occurs in young children and teenagers. While they are considered benign, a cyst can become more invasive and damage the bone’s growth plate or impact the metaphysis (the area where bone shaft and the end of the bone meet).

Unicameral bone cysts treatments are dependent on the likelihood of a fracture or further damage. If necessary, a surgeon will remove

the cyst and fill the remaining cavity with a donor’s bone tissue. Other treatment options may include injection of bone marrow or steroids into the cyst to assist the healing process.

An aneurysmal bone cyst, while still benign, Craig P. Jones, MD has the potential to swell in the bone causing pain and creating an increased likelihood of fractures. Depending on the age of the patient, aneurysmal bone cysts have the potential to deform or damage the bone. Surgery is often a necessity and, with a variety of treatment options, there is a course of action to fit each patient. Most surgeries will involve a curettage, the most common treatment for aneurysmal bone cyst. An instrument called a curette is used to scrape the cyst out of the bone. This process is typically followed by bone grafting to repair the bone.

WHAT IS THE RECOVERY PROCESS AFTER BONE CYST REMOVAL? The recovery process after a bone cyst removal is entirely dependent on the size and severity of the condition. In some cases, patients may resume normal physical activity within four to six weeks of surgery. As bone cysts tend to occur in children and teenagers, there is often a potential for bone cysts to return later in life. According to the American Academy of Orthopaedic Surgeons, unicameral bone cysts return in 25-50 percent of patients.

The risk is higher the younger the child was during the initial treatment. The treatment and recovery processes are the same and your doctor will schedule X-rays regularly to monitor this condition. In Amber’s case, with the addition of the rod in her tibia, she could begin her recovery sooner following the cyst removal procedure. Although it can be a challenging process, physical therapy will allow most patients to return to their normal lifestyle. ”You’ve just got to have the mindset of knowing that it’s going to get better and you’re going to get back to where you were before,” she says. “it just might be a little tough for a little bit, but they’re here to help you get through it.”

WHAT ARE THE RESULTS OF BONE CYST REMOVAL? With the help of Dr. Jones and the team at Orlando Orthopaedic Center, Amber is now able to return to the gym and live the physically active life she wants. She, like many patients, was able to return to her normal lifestyle after the cyst has been successfully removed. “Everyone is here for you and to get you back in your active lifestyle, whatever that may be,” she says. “They always took great care of me and let me know what was going on and where we were at. If anything I feel stronger and better than ever.”  FLORIDA MD - OCTOBER 2015 15

Cancer Genetics and Implications of Testing

By Rebecca Moroose, MD; Ryan Bisson, MS, CGC; Deborah Nosotti ARNP

BACKGROUND: Cancer Genetics is a relatively young but

growing field. Decades ago, Dr. Henry Lynch from Creighton University observed that certain families experienced an inordinate burden of cancer and that these cancers fell into patterns, e.g. colon and rectal cancer, breast and ovarian breast, even pancreatic cancer. His initial ideas were dismissed by the larger medical community. Then Dr. Mary Claire King, an evolutionary biologist, started studying the possible genetic link in families with multiple breast and ovarian cancer and through tedious scientific studies in an era before we had high technology, was able to identify the BRCA1 gene. Subsequently she worked with other scientists to discover the BRCA2 gene. BRCA1 and 2 are perhaps the most well-known genes that lead to a significantly increased risk for breast and ovarian cancer. Angelina Jolie has helped thousands of patients understand the importance of BRCA1/2 when she made public her own personal genetic information and the decision to undergo preventive surgery.

According to the American Society of Clinical Oncology, twice as many women were tested for BRCA1/2 mutations in a North American clinic in the 6 months after the revelation by actress Jolie that she had undergone a prophylactic mastectomy after finding she was a carrier of a deleterious gene, now dubbed “the Angelina Jolie affect”. Dr. Lynch went on to describe an inherited form of colon and endometrial cancer which has been named, Lynch Syndrome. Subsequently over 90 genetic syndromes associated with a wide range of cancers have been discovered.

It is imperative when patients and families are exploring the possibility of inherited cancer risk that they have a comprehensive genetic counseling session and analysis of their genetic risk for cancer and their overall risk for cancer. For example, there are multiple genes and candidate genes that are now known to increase the risk of Hereditary Breast and Ovarian Cancer.

Testing for just BRCA1 and 2 may not be sufficient to rule out genetic cancer risk in some families. Furthermore, additional mutations and large gene rearrangements in BRCA1 and 2 have been identified in recent years, therefore patients who underwent genetic testing years ago may benefit from repeat testing for these newer findings. Analysis of who to test and what tests to do is the role of a Cancer Genetics Program.

It is important to remember that the majority of cancers, 9095%, are not caused by an inherited gene mutation but are caused by mutations acquired through a patient’s lifetime. Therefore, genetic testing alone is not sufficient to determine one’s overall cancer risk and should not replace routine screening.

WHAT ARE THE “RED FLAGS” FOR GENETIC CANCER SYNDROMES? • Early age at diagnosis • Same cancer in 2 or more close relatives – On the same side of the family 16 FLORIDA MD - OCTOBER 2015

– Multiple generations • Multiple primaries or bilateral cancer • Rare cancers • Clustering of cancers consistent with a specific cancer syndrome.

Some examples include: Rebecca Moroose, MD – Breast , ovarian and pancreatic cancer (BRCA1/2) – Breast, thyroid, endometrial and renal cancer (Cowden syndrome) – Breast, sarcomas, adrenocortical and brain tumors (LiFraumeni syndrome) – Colon and endometrial cancer (Lynch syndrome) Also certain tumors, some rare, can be associated with hereditary cancer syndromes: • Triple-negative breast cancer (10-30% have BRCA1 gene mutation) • Male breast cancer (10-15% have BRCA2 gene mutation) • Ovarian/fallopian tube/primary peritoneal cancer (up to 25% is hereditary) • Endometrial cancer diagnosed before age 50 (Lynch syndrome) • Adrenal cortical cancer (14/21 patients in a study had LiFraumeni syndrome) • Medullary thyroid cancer (25% due to MEN2) • Pheochromocytoma or Paraganglioma (Associated with MEN2, VHL and SDH genes) Finally, certain non-cancerous findings can be associated with certain hereditary cancer syndromes: • An enlarged head size (macrocephaly) • Gastrointestinal polyps (hamartomatous versus adenomatous) • Mucocutaneous lesions (multiple trichilemmomas, acral keratosis, multiple mucocutaneous neuromas, multiple oral papillomas especially on the tongue and gingiva, multiple facial papules often verrucous, lipomas, and pigmented macules of the buccal mucosa, the lips, fingers, toes, and external genitalia) • Autism spectrum disorders, mental retardation • Thyroid structure abnormalities • Vascular abnormalities including intracranial developmental venous anomalies.

WHAT ARE THE PROS AND CONS OF GENETIC COUNSELING AND TESTING? Although genetic information that assists patients in taking risk reducing measures can be empowering for many patients, some patients and families do not want to know their risk, especially if the cancer syndrome predicts cancers for which there are no good prevention strategies (e.g. pancreatic cancer). With recent multi-gene panels that can test for multiple genes, sometimes an

unexpected gene mutation will be found that has implications for a different type of cancer risk than the patient and family expected.

There are also testing results called “Variants of Uncertain Significance or VUS” that may lead to uncertainty and confusion for the patient. These issues further underscore the importance of patients meeting with a qualified Genetic Counselor prior to undergoing testing as patients and families are thoroughly counseled about these possible outcomes.

In 2008 the Genetic Information Non Discrimination Act or “GINA” was passed providing protection from genetic discrimination in health insurance and employment for patients seeking Genetic Testing.

WHAT IF A PATIENT TESTS POSITIVE? Currently the National Comprehensive Cancer Network (NCCN) has published evidence based guidelines for patients who carry deleterious germ line mutations. These guidelines include surveillance strategies (e.g. incorporating MRI into screening for high breast cancer risk, younger age of colonoscopy and more frequent colonoscopy for colorectal cancer risk), risk reducing medication (e.g. tamoxifen for reducing breast cancer risk), and risk reducing surgeries (e.g. prophylactic BSO or mastectomy).

WHAT IS THE ROLE OF THE CANCER GENETICS CENTER AT UF HEALTH CANCER CENTER AT ORLANDO HEALTH? The Cancer Genetics Center will provide the full spectrum of care for patients seeking information about Genetic Cancer Risk and Testing. A comprehensive Genetics Focused physical exam and a robust analysis of the family pedigree will be followed by an analysis of potential genetic risk, counseling regarding testing and subsequent testing if appropriate. A follow up appointment will outline results of testing and provide patients and their physicians with a road map to follow for surveillance, risk reducing strategies, and lifestyle changes to mitigate cancer risk. For More Information Contact: UF Health Cancer Center at Orlando Health, Cancer Genetics Center at 321-841-GENE (4363) or Cancer.Genetics@orlandohealth.com.

Rebecca L. Moroose, MD, is board-certified in medical oncology by the American Board of Internal Medicine and serves as a medical oncologist specializing in breast cancer for UF Health Cancer Center – Orlando Health. Dr. Moroose received her medical degree from the University of Connecticut School of Medicine in Farmington. She completed an internship in internal medicine at the University of Maryland Medical Center in Baltimore before returning to the University of Connecticut Health Center to complete her residency in internal medicine, where she served as chief medical resident. She also completed her hematology/oncology fellowship at the University of Connecticut Health Center She served on the founding faculty as an assistant professor of medicine at the University of Central Florida College of Medicine, was the director of the Psychosocial Issues in Healthcare ORTHOPAEDIC Module, and served as the co-chair SUBSPECIALTIES of the Hematology/Oncology Module • SPINE and the Focused Individualized Re• ELBOW search Module. She received the Uni• FOOT & ANKLE versity of Central Florida College of • HAND & WRIST Medicine Visionary Award, selected • HIP by the Class of 2013. She currently • KNEE • ONCOLOGY has an appointment as associate pro• PEDIATRICS fessor of medicine at the University of • SHOULDER Central Florida College of Medicine • SPORTS MEDICINE and is invited to lecture on cancer, co• PAIN MANAGEMENT agulation and genetics. She has pub• PHYSICAL THERAPY lished book chapters as well as many published refereed articles. She is an invited columnist for Orange Appeal SAME DAY, NEXT DAY APPOINTMENTS AVAILABLE magazine. She is a member of the OVIEDO SATURDAY WALK-IN CLINIC American Society of Clinical OncoloNO APPOINTMENT NECESSARY | 9AM - 1PM gy and currently serves on the Parents Downtown Orlando | Winter Park | Sand Lake | Lake Mary | Oviedo | Lake Nona Council of Rollins College. 

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Cost-Savings Program Helps Independent Doctors — McKesson and AID Partner to Form AID-SAVE

By Marni Jameson As independent doctors weather increasing cuts in their reimbursements, one way to help them survive is to help them cut their expenses. This is why members of the Association of Independent Doctors, a national nonprofit devoted to helping doctors stay independent, were excited to learn last month of a new money-saving program they could take advantage of through AID. Working in partnership with McKesson, the nation’s leading supplier of medical supplies, pharmaceuticals, equipment, technology and services, AID-SAVE incorporates two supply-savings programs, and is available to AID members in all 50 states.

Through the program, doctors can save – sometimes significantly -- on almost everything they buy for their practices, including medical supplies, office supplies, equipment and more.

TWO-PART PROGRAM ADDS UP TO BIG SAVINGS

egories: • Office Supplies • Reference Laboratory (program varies by state) • Federal Express • AT&T, Verizon and Sprint Cellular Plans – for both the practice and the employees • US Pay – merchant processing • Imaging Capital Equipment and Contrast Media • More than 1,000 additional contracts are available to AID members!

“Most medical groups will recoup what they spend on their AID dues in one month,” said Don McGahee, who runs the group purchasing side of the program.

SAVE ON EVERYDAY MEDICAL SUPPLIES

“We believe in independent doctors, and want to do all we can to support them,” he said.

Part one of the AID-SAVE program lets members purchase more than two dozen common medical supplies at a discounted rate through McKesson.

To benefit from these savings programs, you must be an AID member. For more information or to join, go to www. aid-us.org or call 407-865-4110.

To start saving, members simply contact their local McKesson account manager, who will confirm the member is a member in good standing. The account manager will then load pricing so the member can access savings. (If you don’t have a McKesson account manager, please contact Kent Olsen, at kent.olsen@ mckesson.com or (904) 624-9414 to find a representative in your local market.)

GROUP PURCHASING OFFERS EVEN MORE SAVINGS Part two of the AID-SAVE program is a collaboration we formed with a group purchasing program that will yield even more savings on over 1.2 million items, including medical supplies, office supplies and equipment. The group purchasing program complements – and does not replace – the McKesson-brand program outlined above.

Though savings will vary among medical groups, most practices can expect to save between 15% and 35% on medical supplies alone through the AID-SAVE group purchasing plan. A test we ran for one large specialty group (and AID member) on one month’s worth of medical supplies found the group would save 19.2% under the new program.

In addition to saving on medical supplies, AID members may also benefit from saving programs available in the following cat18 FLORIDA MD - OCTOBER 2015

Marni Jameson is the executive director of the Association of Independent Doctors. You may reach her at marni@ aid-us.org. 

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HEALTHCARE BANKING, FINANCE AND WEALTH

Five Ways Tech-Savvy Millennials Alter the Health Care Landscape

By Jeff Holt, VP, Senior Healthcare Business Banker with PNC Bank Advances in technology empower millennials to alter health care delivery and insurance, according to a new consumer survey

by PNC Healthcare. Online shopping for doctors, web-based diagnostic tools and research about treatment options at the finger-tips are informing health care decisions for millennials, replacing the single-source, primary care physician favored by older generations.

important to the growth and success of a healthcare,” said Holt.

“Bad patient reviews can come too easy, so making sure positive reviews greatly outnumber the negative ones is a constant challenge for all practices. Getting happy patients engaged with sharing their positive experience will continue to be important for a practice’s success.”

The survey of more than 5,000 consumers nationwide explored the impact of patient-centered care among various age groups, including millennials (ages 21-32), Generation X or Gen-Xers (ages 33-49), baby boomers (ages 50-71) and seniors (age 72+).

• Kick the tires online before buying: Fifty percent of millennials and 52 percent of Generation X-ers checked online information about their insurance options during their last enrollment period compared to 25 percent of seniors.

Seniors prefer printed materials (48 percent) or a company representative (38 percent) before selecting their plan.

“As millennials overtake boomers as the nation’s biggest consumer buying group, they will expect more efficient ways to make healthcare payments via digital channels that are consistent with their experiences in other industries,” said Jeff Holt, vice president, senior healthcare business banker with PNC Bank. “It will be important for payers and providers to work together to meet these payment expectations by progressing further along the technology continuum, especially considering that much of the growth in the healthcare payments industry has been driven by a rise in patient responsibility. Those insurers and health care providers that thrive will be those that adapt sooner than later to the preferences of this fast-paced, technology-driven generation.”

Growing trends among the millennials that are driving change in health care include: • Speedy Delivery: When it comes to the drive-thru generation, millennials prefer retail (34 percent) and acute care clinics (25 percent) double that of boomers (17 and 14 percent respectively) and seniors (15 and 11 percent respectively). On the flip side, seniors (85 percent) and boomers (80 percent) visited the primary care physician (PCP) significantly more than millennials at 61 percent.

In Florida, Holt says that Urgent, Specialty and Retail clinics over the last four years have grown dramatically. “Quick Care” availability has been recognized as a top priority by many healthcare organizations, and even large retailers and several pharmacy chains. The concern amongst some millennials is with this method of care and the quality of the patient’s care based on who is consulting with the patient (level of education), possible lack of patient’s accurate healthcare background, and pressure of being a “quick” appointment.”

• Word-of-Mouth Marketing: Nearly 50 percent of millennials and Gen-Xers use online reviews (e.g. Yelp, Healthgrades) when shopping the last time for a health care provider, compared to 40 percent of baby boomers and 28 percent for seniors.

“The timely management of Social Media is critically

• Good faith, upfront estimates: One out of five people surveyed

by PNC listed unexpected/surprise bills as the No. 1 billingrelated issue. With out-of-pocket costs on the rise, millennials are more inclined (41 percent) to request and receive estimates before undergoing treatment. Only 18 percent of seniors and 21 percent of boomers reported asking for or receiving information on costs upfront. Unfortunately, 34 percent noted the final bill was higher than the estimate; only eight percent reported a bill lower than estimate.

“What we’ve found with our clients in the Southeastern U.S, is that healthcare practices are now more motivated than before to improve the patient’s experience around billing, payment plans, and care & insurance coverage education due to the need to comply with healthcare reform requirements and for the sake of improving the profitability of the practice,” added Holt.

• Kicking care down the road: All age groups agreed that medical care is too expensive (79 percent) and health care costs are unpredictable (77 percent). But more than half of the millennials (54 percent) and Gen-Xers (53 percent) reported delaying or avoiding treatment due to costs compared to seniors (18 percent) and boomers (37 percent).

“What we’ve found locally,” added Holt, “is that with many patients neglecting their care due to costs, practices are addressing this issues by offering free/low cost healthcare clinics, healthcare education, and automated patient payment programs.”

For more than 20 years, PNC Healthcare, a member of The PNC Financial Services Group, Inc. has delivered an array of integrated solutions designed to meet the unique financial and banking needs of healthcare providers and insurers.

The PNC Financial Services Group, Inc. ([www.pnc.com] www.pnc.com) is one of the United States’ largest diversified financial services organizations, providing retail and business FLORIDA MD - OCTOBER 2015 19

HEALTHCARE BANKING, FINANCE AND WEALTH banking; residential mortgage banking; specialized services for corporations and government entities, including corporate banking, real estate finance and asset-based lending; wealth management and asset management.

METHODOLOGY This information comes from a survey commissioned by PNC Healthcare and conducted by Shapiro+Raj in January 2015 with a nationally representative sample of 5,092 American adults age 21+. The survey was primarily conducted online, supplemented with 300 telephone surveys. Total sample is +/- 1.4 percent at the 95 percent confidence level; the sampling error for age cohorts range from +/-2.2 percent to +/- 4.9 percent at the 95 percent confidence level. The first stage of the research, conducted in August 2014, involved in-depth telephone interviews with hospital executives around the country to identify trends, challenges and new innovations in patient-centered care. The second stage of the research, conducted in October and November 2014, consisted of 12 exploratory focus groups with American adults in four U.S. markets and across six segments (Uninsured, Chronic Conditions, Millennials, Medicare, High Income, and Families with Children). The findings from first two stages shaped the hypotheses and questions asked in the third, quantitative, stage.

Jeff Holt is a Senior Healthcare Business Banker with PNC Bank’s Healthcare Business Banking and can be reached at (352) 385-3800 or Jeffrey.holt@pnc.com.

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COMING UP NEXT MONTH: The cover will be about the brand new Florida Hospital for Women.

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RAVENHEART GRAPHIC DESIGN • ILLUSTRATION • PHOTOGRAPHY •

407-292-6609 • 407-414-3359 20 FLORIDA MD - OCTOBER 2015

Nutrition and Cancer: Is Losing Weight During Treatment a Bad Thing?

By Amber Orman, MD, assistant member of the Department of Radiation Oncology at Moffitt Cancer Center

The prevalence of obesity (body mass index, BMI ≥ 30) in 2009-2010, was 35.8 percent among U.S. adult women according to the National Health and Nutrition Examination Survey1.

In a prospective study including nearly 500,000 women who were free of cancer at enrollment, the heaviest women (BMI ≥ 40) had death rates from all cancers combined that were 62 percent higher than the rates of death in women of normal weight.

When examined individually, BMI was significantly associated with higher rates of death due to cancers of not only the breast, uterus, cervix, and ovaries, but also cancers of the esophagus, colon and rectum, liver, gallbladder, pancreas, and kidney, as well as non-Hodgkin’s lymphoma and multiple myeloma. Collectively, it is estimated that overweight and obesity accounts for 20 percent of all cancer related death in women2. Obesity will soon surpass tobacco to become the number one preventable cause of cancer. In addition to causing cancer, obesity is linked to poorer cancer outcomes and response to treatment, as well as increased risk of developing second primary malignancies3. It follows that obesity itself is now categorized as a disease-state by the American Medical Association; a disease state that all physicians, especially those in oncology, should be equipped to manage.

We physicians generally fear weight loss in cancer patients because we are classically taught that it is a poor prognostic indicator.

Too often I hear cancer patients being told, “Eat whatever you want, and a lot of it. We don’t want you losing weight.” However, it is important to keep in mind that overweight people can also be undernourished, commonly in the form of excess fat and muscle loss, a condition known as sarcopenic obesity. It is not the number on the scale that we should be watching, but the actual nutritional status and body composition of our patients. So should we tell women who are already devastated by a diagnosis of cancer to also go on a diet? I believe the answer is yes… well sort of.

The traditional thinking is that to lose weight, we should be eating fewer calories. A simple illustration will demonstrate the flaw in this logic. Consider 1000 calories of kale and 1000 calories of French fries. Despite the glaring nutritional differences between these two foods, if the traditional dogma of “caloriesin-calories-out” were true, assuming all other factors were kept equal, we would observe no difference in body weight or composition between people eating all kale vs all French fries. However we all know this is not the case, and we now have good evidence highlighting the effects of different calorically equivalent “diets” on body composition, as well as levels of systemic inflammatory markers4.

I find that the best way to empower my female patients during this difficult time is to assess their readiness and current nutritional awareness, and tailor my recommendations accordingly. I focus not on the things they “can’t eat,” but on the new interesting foods and supplements they can now explore and enjoy, highlighting the benefits associated with these changes in terms

of oncologic outcomes, treatment related toxicities, and overall quality of life.

Benefits especially appealing to women include an improvement in hot flashes, brighter skin, clearer mentation, and better sleep quality.

One key component of my recommendations involves the consumption of fermented foods. We are becoming increasingly aware of the effects of the composition of the microbiome not only on digestion, but also on mental health, immune system function, and even the risk of obesity itself5. A diet rich in fermented foods encourages an optimal balance of “good” to “bad” gut bacteria, and these foods can contain up to 10 trillion colonyforming units (CFUs) of bacteria per serving (compared to a typical 50 million to 10 billion CFUs per probiotic pill).

Many other integrative therapies play a role in the whole-patient care we deliver at Moffitt. Female patients frequently inquire about these types of interventions, and at least half of them have already received some sort of integrative therapy. For my female cancer patients, I stress the importance of not only nutritional approaches, but also incorporate a variety of physically and mentally supportive services available at Moffitt. These include relaxation techniques such as yoga, meditation, massage, deep breathing, and guided imagery, as well as acupuncture, art and music therapy, and individual and group counseling services. We also offer spiritual support and have clinically trained chaplains on staff.

The final and often most important aspect of care occurs after all cancer-specific treatments have been completed. Unfortunately this period of time, known as cancer survivorship, is often overlooked and patients are left without much guidance. This is an opportunity for health promotion to not only decrease the risk of a subsequent battle with cancer, but also minimize comorbidities and improve overall health long term. It is our duty as physicians to empower patients as they move forward after a diagnosis of cancer.

Footnotes: 1 PMID: 22253363 2 PMID: 12711737 3 PMID: 23529000 4 PMID: 22735432 5 PMID: 23571517

Amber Orman, M.D. is an assistant member in the Department of Radiation Oncology, with a secondary appointment in the Department of Oncologic Sciences at the University of South Florida. Orman’s clinical focus is breast cancer, with an emphasis on holistic care that encompasses both mind and body. Her primary research interest is in integrative therapies and their applications to cancer prevention, treatment, and survivorship. She believes in treating not only the cancer at hand, but also the whole patient, using interventions that increase quality of life both during and after treatment. She is especially focused on nutrition and the microbiome.  FLORIDA MD - OCTOBER 2015 21

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