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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
5
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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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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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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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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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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
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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.
37
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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
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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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Baptist Cancer Institute 2014 ANNUAL REPORT
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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