Florida Hospital North Pinellas Oncology Annual Report 2013

2013 annual report

DIE GU IDE

Using Statistical Data From 2012

DIE GU IDE

ONCOLOGY

Philosophy and Mission Statement As one of the premier providers of cancer care in Pinellas, Pasco and Sumter Counties, we exist to offer comprehensive care to our patients and families from early detection through screening, efficient diagnosis, cutting edge treatment, and compassionate end-of-life care.

Our commitment is to provide the latest technology and compassionate care to each individual. It is our goal to meet your physical, emotional and spiritual needs throughout your health care experience.

1

Our Mission OUR VALUES

Adventist Health System employees draw motivation and direction from six strongly held principles. These principles guide the manner in which we treat each other and those we serve.

CHRISTIAN MISSION

We exist to serve the needs of our communities in harmony with Christ’s healing ministry and incorporate Christian values at every level of service.

QUALITY AND SERVICE EXCELLENCE

We strive to meet or exceed both the service standards of the health care industry and expectation of the patients we serve and measure our success through continuous surveying of patient satisfaction.

COMPASSION

We are sensitive to the needs of the individuals and families we serve and meet their needs with kindness and empathy.

FOCUS ON COMMUNITY WELLNESS

We commit time, talent and financial support to educate our neighbors in the principles of illness prevention and healthful living.

HIGH ETHICAL STANDARDS

We conduct our business with integrity, honest and fairness. As responsible stewards, we use our financial resources wisely by choosing business practices which are cost-effective, productive and result in a fair return on investment.

CULTURAL DIVERSITY

We value the diversity of our patients, employees, business colleagues and visitors and treat them with kindness and respect regardless of their background, race, religion or culture.

2

Table of Contents President and CEO 4 Cancer Committee 5 Cancer Committee Members 6 Annual Report Editorial Board 7 Credentialed Physicians 8 Oncology Services Directory 9 Spiritual Care 10 Chairman’s Report 12 Administrative Report 14 FHNP Programs & Services 2013 16 Breast Health Program 18 Melanoma & Cutaneous Oncology Program 22 Gastrointestinal Oncology Program 26 Thoracic Oncology Program 28 Head & Neck Program 30 Urologic Oncology & General Urology 31 Plastic & Reconstructive Surgery 32 Cancer Screening Program 34 Community Outreach 37 Presentations 38 CME Lectures 39 Interviews 39 Community Supported Events 39 Fundraisers 39 Oncology Research 40 Genetic Counseling & Testing 42

Integrative Oncology Multidisciplinary Cancer Conference Imaging Department Pathology & Laboratory Medicine Clinical Studies Care Navigation Oncology Nursing Patient Experience Specialist Palliative Care Wound Care & Hyperbaric Medicine Case Management Supportive Services Community Partnership with the American Cancer Society Cancer Registry Top Sites Primary Site Table Based on 2012 Statistics Definition of Terms Touching Lives Through Philanthropic Support Looking Forward

43 44 45 46 48 52 53 54 55 56 57 58 61 62 62 63 66 67 68

3

President and CEO Florida Hospital North Pinellas is dedicated to providing the highest quality, patient-centered care for our community. The Florida Hospital North Pinellas Oncology Program exists to offer comprehensive and compassionate care to our patients and their families, beginning from the very first stage of cancer detection.

erm EO h C g r Be and e nt uc Br eside Pr

I am proud of how our program has made great strides in expanding our community’s access to exceptional cancer care, and has continually strived to identify opportunities for growth. We have enhanced our Breast Health Program by incorporating state-of-the-art technology, expanded our Surgical Program with the addition of the da Vinci Surgical System, and have improved the scope of our Diagnostic Imaging services by installing a 64-slice CT Scanner. Our Florida Hospital North Pinellas Physician Group and Surgical Institute offer the knowledge and expertise of some of the region’s leading physicians. Our physician group represents a large range of specialties, including Surgical Oncology, Plastic and Reconstructive Surgery, Thoracic and Vascular Surgery, and Colorectal Surgery. Additionally, our program and physicians provide Melanoma and Cutaneous Oncology, Gastrointestinal Oncology and Urologic Oncology care.

As an organization, we have made it our mission to reach out to our community by offering countless physician lectures and free health screenings, reaching more than 10,000 community members in 2013 alone. We are also excited with the immense success of our Operation Sunshine skin cancer screening program, begun in 2012, that has impacted the lives of more than 1,000 of our community residents.

Many of the free screenings provided at local businesses and organizations have truly saved lives. Our Imaging, Pathology and Rehabilitation departments are also all active in the process of detection and cancer care for our patients, and are aided by a variety of support services to ensure a continuum of care.

As a part of the Adventist Health System, we believe in extending the healing ministry of Christ and healing not just the body, but the mind and spirit. This level of spiritual care is extended to every patient and family member in our care. We depend on the talents of our staff, the facilities of our hospital, and the support of our community to continue to care for those who face the uncertainty and fear of a cancer diagnosis.

Addressed in the enclosed report you will find more information that features the many achievements and recognitions attained by our Oncology Program, as well as those future goals we endeavor to reach over the next several years. Thank you for your continued support and dedication to our community’s health and well-being.

Together in service, Bruce Bergherm President & CEO Florida Hospital North Pinellas

4

Cancer Committee In 2012, Florida Hospital North Pinellas (FHNP) organized a Cancer Committee for the purpose of providing superior and guide-line driven care to patients with cancer. It is a multidisciplinary committee comprised of medical staff and representatives from each of the departments involved with the care of cancer patients. The committee convenes every other month and provides leadership and professional guidance for the Florida Hospital North Pinellas Oncology Program. The focus of this committee is to develop annual goals and objectives for programs related to cancer, promote an organized approach to patient management, oversee monthly consultative Cancer Conferences (Tumor Boards), review patient care evaluation studies, oversee Performance Improvement activities, identify and implement clinical research protocols, supervise the Cancer Registry to ensure accuracy, and to provide leadership for community screening and education programs.

Our Oncology Program has seen a very productive year, with involvement in numerous community and charitable initiatives, including committee chair positions for Doctor Idol Tampa Bay, Operation Sunshine and Relay for Life (Tarpon Springs and Oldsmar). Other successes and additions to the program this year included the development and implementation of the Cancer Screening electronic database, which now allows us to query data points on patients screened for skin cancer, utilizing more than 150 variables. This data will be invaluable, as we will be able to predict outcomes as well as provide a “needs assessment� for the Pinellas County population.

Ro Dir sema ect ry or Giu , O lia nc no olo , A gy RNP Pr , M og ramSN

Florida Hospital North Pinellas is seeking the prestigious American College of Surgeons (ACoS) Commission on Cancer (CoC) accreditation in 2015. Nationally, including Puerto Rico, CoC-accredited programs represent 30% of the general medical-surgical hospitals and provide care to close to 70% of patients who are newly diagnosed with cancer each year.

Sincerely, Rosemary Giuliano, ARNP, MSN Director, Oncology Program Florida Hospital North Pinellas Clinical Instructor USF School of Nursing

5

Florida Hospital North Pinellas

Cancer Committee Members Committee Chairman Douglas Reintgen, MD, FACS Cancer Liaison Physician Douglas Reintgen, MD, FACS Surgeon Douglas Reintgen, MD, FACS Medical Oncology David Wenk, MD Radiation Oncology Lawrence Hochman, DO, FACRO Administration Karen Owensby, MSN, RN Diagnostic Radiology David Vargas, MD Pathology Jeffrey Smith, MD, FCAP Oncology Nurse Donna Stoehr, RN. CRRN Cancer Registry/ Cancer Registry Quality Coordinator Randy Slavens, CTR Performance Improvement/Quality Paula Feit, RN, MSHL, LHRM Case Manager Kathryn Welch, MSN, RN, CCM Palliative Care Team Member Stacy Orloff, Ed.D, LCSW, ACHP-SW

Coordinators Cancer Conference Coordinator Louis Astra, MD, FACS Quality Improvement Coordinator Paula Feit, RN, MSHL, LHRM Cancer Registry Quality Coordinator Randy Slavens, CTR Community Outreach Coordinator Christine Longely, MS, BS Clinical Research Representative Rosemary Giuliano, ARNP, MSN Psychosocial Services Coordinator Stacy Orloff, Ed.D, LCSW, ACHP-SW

2013 Sub-Committee Members Specialty Physicians Raj Kotak, MD, FACS

Effie Pappas Politis, MD, FACS, ABPS

Lourdes Santiago, MD, FACS Registered Dietitian Bobbi Sheffield, RD, LD/N Pharmacist Gary Avila, R. Ph American Cancer Society Robert Breakiron, MBA Patient Experience Coordinator Danielle Rucker Pastoral Care Representative Larry Black, Dmin, MDiv Rehabilitation Representative Ryan Grella, PT, DPT, OCS Patient Care Navigator Katherine Fondren, ARNP-C, MSN Mammography Supervisor Adrienne Herman, R.T. (R)(M) Clinical Education Specialist Thomas Mazzant, MSN, RN, CPN

6

Florida Hospital North Pinellas

Annual Report Editorial Board Paul M. Arnold, MD, FACS

Paul S. Hoover Jr.

Cynthia Roever, MD

Louis I. Astra, MD, FACS

Nuruddin Jooma, MD

Danielle M. Rucker

Raj P. Kotak, MD, FACS

Lourdes Santiago, MD, FACS

Urology Urology Specialists of West Florida Thoracic/Vascular/General Surgery Florida Hospital North Pinellas Florida Hospital North Pinellas Physician Group

Gary Avila, R.Ph

Vice President Business Development Florida Hospital North Pinellas Medical Oncology Florida Cancer Specialists & Research Institute

Geriatric Medicine Florida Hospital North Pinellas Physician Group Patient Experience Coordinator Florida Hospital North Pinellas

Pharmacist Florida Hospital North Pinellas

Surgery Florida Hospital North Pinellas Florida Hospital North Pinellas Physician Group

Tina Baum, MS, CNS, CWOCN

Christine Longley MS, BS

Jose A. Berrios, MD, FACS

Arthur J. Matzkowitz, MD

Radiation Oncology Florida Cancer Specialists & Research Institute

Clinical Nutrition Manager Morrison Healthcare Food Service Florida Hospital North Pinellas

Larry Black, DMin, MDiv, BCC

Thomas Mazzant, MSN, RN, CPN

Jeffrey B. Smith, MD, FCAP

Keith G. Chisholm, MD, FACS

Stephen F. Morris, MD, FCAP

Wound Ostomy and Continence Nurse Florida Hospital North Pinellas

Head and Neck Surgery /Otolaryngology Gulf Coast Ear Nose & Throat Chaplain Florida Hospital North Pinellas General Surgery Surgical Specialists of Trinity

Uday Dandamudi, MD Medical Oncology Florida Cancer Specialists

Katherine Fondren, ARNP-C, MSN

Surgical Hospitalist Florida Hospital North Pinellas Florida Hospital North Pinellas Physician Group

Rosemary Giuliano, ARNP, MSN

Community Outreach & Volunteer Manager Florida Hospital North Pinellas

Clinical Education Specialist Florida Hospital North Pinellas

Pathology Florida Hospital North Pinellas Department of Pathology and Laboratory Medicine Laboratory Medical Director/ Laboratory Services Director

Stacy F. Orloff Ed. D., LCSW, ACHP-SW

Vice President Palliative Care and Community Programs Suncoast Hospice

Karen Owensby, MSN, RN

Vice President, Chief Clinical Officer Florida Hospital North Pinellas

Director, Oncology Program Florida Hospital North Pinellas Florida Hospital North Pinellas Physician Group Clinical Instructor USF School of Nursing

Ravi Patel, MD, M.B.B.S., FACS, FICS, FCCWS, ABPM-UHM

Ryan J. Grella, PT, DPT, OCS

Effie Pappas Politis, MD, FACS, ABPS

Director of Rehabilitation Florida Hospital North Pinellas

Vivian Griffin, MD

Radiation Oncology Florida Cancer Specialists

Richard Hamill, MD

Dermatology Gulf Coast Dermatology

Lawrence Hochman, DO, FACRO Radiation Oncology Florida Cancer Affiliates

President and Chief Medical Officer, Innovative Healing Systems Chief of Surgery – Florida Hospital Carrollwood, Tampa Medical Director of North Pinellas Plastics/Reconstructive Surgery Florida Hospital North Pinellas Physician Group Assistant Professor Division of Plastic & Reconstructive Surgery University of South Florida

Douglas S. Reintgen, MD, FACS

Surgical Oncology Florida Hospital North Pinellas Physician Group Director, Cancer Initiatives Professor of Surgery University of South Florida

General and Colorectal Surgery Florida Hospital North Pinellas Physician Group

Debra A. Schneider, MD

Radiology Florida Hospital North Pinellas

Bobbi Sheffield RD, LD/N

Associate Pathologist Florida Hospital North Pinellas

Terry B. Smither

Executive Director Helen Ellis Memorial Foundation in support of Florida Hospital North Pinellas

Christine Sparks, AS

Cancer Screening Program Coordinator Florida Hospital North Pinellas

Donna Stoehr, RN, CRRN

Oncology Nurse Florida Hospital North Pinellas

David Vargas, MD

Radiology Florida Hospital North Pinellas

Kathryn Welch, MSN, RN, CCN Director, Case Management Florida Hospital North Pinellas

David T. Wenk, MD

Medical Oncology Florida Cancer Specialists & Research Institute

Gail L. Shaw Wright, MD, FACP, FCCP

Medical Oncology Florida Cancer Specialists & Research Institute

Cancer Registry Team: Sandra Carlson, CTR Jimmie Lee Cummins, BS, CTR Randy L. Slavens, CTR Angela Swilley

7

Florida Hospital North Pinellas

Credentialed Physicians Ear/Nose/Throat

Pathology

Surgery

James S. Barna, MD Jose A. Berrios, MD Jerry A. Margolin, MD Christopher D. Muller, MD Michael J. Sakellarides, MD Jason L. Swerdloff, MD

Stephen F. Morris, MD Jeffrey B. Smith, MD

William W. Angell, MD Louis I. Astra, MD Carol M. Brewer, MD Keith G. Chisholm, MD Peter T. DiNapoli, MD Hadi A. Hakki, MD Venkit S. Iyer, MD Raj P. Kotak, MD David F. Marler, MD Isidoros J. Moraitis, MD Lester C. Ordiway, MD James H. Oury, MD Louis M. Palermo, MD Effie Pappas Politis, MD Douglas S. Reintgen, MD Michael J. Sakellarides, MD Lourdes T. Santiago, MD Thomas J. Umstead, MD Vic Velanovich, MD John J. Zelis, MD

Dermatology

Randall C. Harrell, MD Isidoros J. Moraitis, MD Effie Pappas Politis, MD

David A. Lam, MD Panayiotis Vasiloudes, MD

Pulmonary Medicine

Hospice/Palliative Medicine Kevin A. Ache, DO Wayne C. Anderson, MD Kerry L. Englert, DO Robert B. Killeen, MD

Medical Oncology/ Hematology Roberto A. Araujo, MD Jorge Ayub, MD Norman J. Brodsky, MD Uday B. Dandamudi, MD Robert L. Drapkin, MD Michael D. Gauwitz, MD Madhu Goyal, MD Vivian D. Griffin, MD Sneh L. Gupta, MD Nuruddin Jooma, MD Robert B. Killeen, MD Idelfia A. Marte, MD Edgar Gerardo Miranda, MD Fadi E. Nakhl, MD Shilen N. Patel, MD Max Rafael Pena, MD Gerald H. Sokol, MD Nathan Isvaran Visweshwar, MD David T. Wenk, MD Gail L. Wright, MD 8

Plastic/Reconstructive Surgery

Zahid M. Akram, MD Imran A. Khan, MD Navnit K. Kundra, MD Amir A. Noorani, MD

Psychiatry Irene A. Nickolakis, MD

Radiation Oncology Norman J. Brodsky, MD Michael D. Gauwitz, MD Vivian D. Griffin, MD Lawrence D. Hochman, DO Arthur J. Matzkowitz, MD Max R. Pena, MD Gerald H. Sokol, MD

Radiology; Diagnostic Debra A. Schneider, MD David J. Vargas, MD

Radiology: Interventional Gerald A. Niedzwiecki, MD David J. Vargas, MD

Urology Paul M. Arnold, MD Yaser S. Bassel, MD David J. DiPiazza, MD Brian Hale, MD David Jacob, MD Ramon Perez, MD Sobhy D. Shehata, MD Paul M. Vazquez, DO

Florida Hospital North Pinellas

Oncology Services Directory Administration

Health Information

Pharmacy

American Cancer Society

Helen Ellis Memorial Foundation in support of Florida Hospital North Pinellas

Rehabilitation Services

(727) 942-5107 Fax: (727) 942-5161

(727) 812-7012 Fax: (727) 545-3753

Cancer Registry (813) 615-7859 Fax: (813) 615-8115

Cancer Screening (727) 943-3659 Fax: (727) 756-7602

Chaplain’s Office (727) 943-3668

community outreach (727) 943-3698 fax (727) 756-7602

Comprehensive Breast Center (727) 942-5012 Fax: (727) 942-5117

FHNP Physician Group Surgical Institute (727) 934-6797 Fax: (727) 942-6503

Genetic Counseling at USF (813) 259-8772 Fax: (813) 259-8771

(727) 942-5024 Fax: (727) 943-3673

(727) 943-3651 Fax: (727) 756-7684

Imaging

(727) 942-5012 Fax: (727) 942-5117

Nurse Educator (727) 942-5089

Nursing Supervisor (727) 942-5000

(727) 942-5030 Fax: (727) 942-5085

(727) 942-5033 Fax: (727) 943-3436

Social Services (727) 942-5188 Fax: (727) 945-5185

University of South Florida (813) 974-2201

Volunteer Program (727) 942-5000 Fax: (727) 756-7630

Nutrition

(727) 942-5000 x2997 Fax: (727) 943-3492

Oncology Program Director (727) 934-6797 Fax: (727) 942-6503

Pathology

(727) 942-5014 Fax: (727) 942-5016

Patient Experience Specialist (727) 943-3621 Fax: (727) 942-5161

9

Spiritual Care Florida Hospital North Pinellas is a faith-based hospital that believes total patient care includes attention to the spiritual and emotional, as well as the physical needs of each patient. Thus, spiritual care is included in the treatment of the patients and families who visit our hospital.

This care is provided by the Spiritual Care team—the Chaplain, Spiritual Ambassadors and spiritual caregivers—who use our guest’s specific spiritual or religious tradition to address the present needs within his/her unique circumstances, framework of meaning and spiritual expression.

CC B , iv MD , in DM , ack l B rry lain a L ap Ch

The Spiritual Care team consists of a variety of Christian faith traditions, both liturgical and nonliturgical. Patients and families can choose to receive visits from them or they may request assistance in contacting a representative from their own faith community.

The Spiritual Care team works with and is included in the multidisciplinary care team. And as part of the multidisciplinary care team, they offer integrated care—psychological and spiritual—when responding to the diverse spiritual and emotional concerns experienced by patients and those who care for them—their family, friends and health care staff.

Members of the Spiritual Care team are available to offer counseling and emotional support to our patients, families, and health care staff, as well as provide a support system to help them cope during a patient’s illness and if necessary, afterwards during their own bereavement.

Additional services provided by our Spiritual Care team include: spiritual assessment, consultations on advanced directives, end-of-life decisions and ethical concerns.

Sincerely, Larry Black, DMin, MDiv, BCC Chaplain Florida Hospital North Pinellas

10

But I will hope continually, and will praise You yet more and more.

Psalm 71: 14

11

Chairman’s Report

CS A F , MD , n tge n i y e . R olog S c s gla al On u Do rgic Su

I would like to take this opportunity to welcome our readers and our patients to the second annual Oncology Annual Report for the Florida Hospital North Pinellas (FHNP). It has been an interesting and exciting second year at the former Helen Ellis Memorial Hospital. The hospital and the cancer services continue to reap the benefits from its ownership by Adventist Health System, a national hospital chain of 44 campuses with 26 hospitals in the state of Florida. With their brand they have invested over $45 million in the facility, with fresh paint on the exteriors, refurbished wards and rooms in the hospital, the latest technology in radiology, vascular suite and the OR, and new highly-skilled and trained staffing.

Adventist Health System has also entered into a partnership with the University of South Florida (USF) to build Surgical Institutes and Centers of Excellence in various hospitals throughout the state of Florida.

The Surgical Institute of FHNP was created to serve the needs of the local community in Tarpon Springs, north Pinellas and west Pasco County.

This partnership brought myself, Douglas Reintgen MD, a Professor of Surgery and Director of Cancer Initiatives at USF, to practice at FHNP. While at USF in the 1990s, I was part of the team that helped to develop the lymphatic mapping and sentinel node biopsy technique for the surgical treatment of melanoma and breast cancer, a technique that quickly became the standard of care throughout the world. I specialize in the surgical treatment of early stage breast cancer and melanoma, the most deadly skin cancer. Along with me came Effie Pappas Politis, MD, a Plastic Surgeon with a Greek heritage. Dr. Pappas Politis specializes in breast reconstruction after mastectomies but also helps care for patients with skin cancers in the head and neck region. In addition, she has opened a cosmetic practice of injections, fillers and lifts to beautify patients with these services in the community. Rounding out the group is Louis Astra, MD, a thoracic, vascular and general surgeon. A jack-of-all trades, Dr Astra fills many holes in coverage for the hospital. With a high volume practice he provides for the surgical care of patients with lung cancer and the technically demanding surgery for esophageal tumors. A recent recruit to the Surgical Institute is Lourdes Santiago, MD, Raj Kotak, MD both colorectal and general surgeons. They will be adding their expertise to the care of patients with tumors of the lower gastrointestinal tract. The person that holds all this together and provides the day-to-day direction and organization for the group is Rosemary Giuliano, ARNP, who is the Director of Oncology at FHNP. Most patients will come into the cancer services of an organization through the surgical service, as surgery is usually the first treatment with either a biopsy or definitive treatment. However to achieve the best results with many of the adult cancers, multi-disciplinary care is needed and community medical and radiation oncologists have embraced their role in the cancer program, participating in the monthly Tumor Boards and prioritizing appointments for cancer patients in the system. One can see from the list of participants for each of the cancer programs in this report that community support is vital for the success of the program.

12

A monthly Tumor Board has been established to discuss difficult or controversial cases in order to develop a consensus on how best to treat the patients. Cases are presented with pathology and radiology input, clinical guidelines are discussed and clinical research eligibility is ascertained. Clinical research can be important in a community setting since it gives local patients access to the newest drugs, techniques or treatments for their cancer. The MINT trial was instituted for the Cancer Program which is a nationwide trial evaluating the role of gene expression profiles in the treatment of women with advanced breast cancers. Other trials are available through the community medical oncology practices.

Technology for cancer patients has been upgraded at FHNP. Digital mammography is available that eliminates the need for film and developing agents and allows all the images to be digitalized and universally available throughout the campus. Breast MRI, a more sensitive examination than mammography, is also available for women who are younger and those with dense breast tissue. The Women’s Center has opened in the hospital, an area where women can have the utmost privacy for the work-up of their abnormal mammograms. One day/week a mobile PET/CT scanner comes to the campus so that cancer patients can have this examination and see their physician with one trip. This technology can be costly and thanks goes out to the Adventist Health System for bringing these improvements to the community. Florida Hospital North Pinellas also received the HIMMS analytic Stage 7 award for attainment of the highest level of electronic medical records adoption model, placing our organization in the top 1.9 percent of hospitals nationwide. Additionally, the purchase of a da Vinci Surgical System with the support of our Foundation, means that our surgeons are able to perform some of the most technologically advanced surgical procedures available.

Teaching is an important function of any academic organization and the best hospitals in the country are associated with medical schools. FHNPs partnership with USF allows for such an interaction as the faculty of the Surgical Institute teach an Introductory Cancer 101 course to first and second year medical students at USF. In addition FHNP supports and hosts a summer internship program on campus where undergraduate students from the community interested in a medical career can shadow physicians from the Surgical Institute and the community. The students become active participants in the care of the cancer patients as they see patients in the clinic, participate in hospital rounds, and scrub into the OR to assist. Rotations this past summer were in surgical, medical and radiation oncology, plastic surgery, thoracic and vascular surgery, family practice, ear, nose and throat, radiology, pathology, anesthesiology, and urology. Students were also challenged to participate in a clinical research project or write a case report that could be published in the medical literature. In this way their CV’s may be improved for applications to medical schools and residencies.

The major fund raiser for FHNP took place on November 9, 2013 and featured a “Doctor Idol” competition of physician bands performing for the attendees. The evening was a huge success with over $50,000 being raised and much fun for the attendees. The main benefactor for the gala was “Operation Sunshine.” In this program, staff of the Surgical Institute will hit the streets in a truck generously donated by Sun Toyota to provide on-site skin cancer education and screening to schools and industry in the north Pinellas area. Skin cancer and melanoma are an epidemic in the State of Florida and with this community program, staff and employees will not have to take personal time to receive what may be a life-saving screen.

The future is bright for the oncology program at FHNP and excitement is at an all-time high. People in the community are invited to attend our community outreach education programs and encourage your employer to participate in Operation Sunshine. Above all get to know and support your community hospital as investments continue to be made in the health and well-being of Tarpon Springs and surrounding areas.

Respectfully submitted, Douglas S. Reintgen, MD, FACS Surgical Oncologist USF Professor of Surgery Director of Cancer Initiatives FHNP Commission on Cancer Chairman and Liaison Florida Hospital North Pinellas Physician Group

The Florida Hospital Tampa region also made another exciting partnership this year with Tampa General Hospital. This new partnership will help to create new programs and enhance existing services throughout the Tampa region.

13

Administrative Report The oncology team of Florida Hospital North Pinellas is again pleased to offer our Annual Report to the community. We are proud of our accomplishments as we continually strive to improve our cancer program. On behalf of the Cancer Committee, we invite you to review this report as we describe the work of our team.

N ,R r N MS ffice , y b O ensnical w n O f Cli e r Ka Chie VP,

Our multi-disciplinary approach to cancer care is reflected in this annual report. You will see reports from our physicians and nursing staff, rehabilitative care, pastoral care, nutritional team, and case management, from our community liaison and from our tumor registrar. Together, we work to make sure we deliver the very best in oncology care.

Each year, we set goals as a cancer committee to assure our program is continually improving. You will see these improvements presented in this report.

Involvement in our community is strong as we partner with our community for health promotion and screening. Many events are highlighted in this report.

Our oncology program has experienced another year of growth. We look forward to 2014 and beyond as we improve care offered to our community.

Sincerely, Karen Owensby, MSN, RN Vice President, Chief Clinical Officer Florida Hospital North Pinellas

14

15

FHNP Programs & Services 2013 Cancer Screening

• Cancer screenings at health fairs and education series • Operation Sunshine – skin cancer screening in schools, industry and community settings

Emergency Department • Chest Pain Accreditation • Primary Stroke Center

Genetic Counseling and Testing – USF and Community Partnership • Genetic counseling regarding a patient or family members’ individual risk of carrying an inherited genetic mutation

Imaging Services

• PET/CT scanning • CT (64-slice) Coronary CTA • Image-guided breast biopsy Breast-Stereotactic Ultrasound-guided • MRI Defecography • Fixed site screening and diagnostic digital mammography with CAD • Dexa Scan

Integrative Oncology Community Partnership • Mind-body therapies • Nutritional strategies • Acupuncture

Infusion Center

16

• • • • • • • •

Chemotherapy infusions by chemotherapy certified nurses Blood transfusions PICC line & midline insertion and maintenance Maintenance of vascular access ports Antibiotic therapy Reclast infusions Iron infusions Hydration therapy

Laboratory Services/ Pathology Services

• Rapid Processing of all specimens, special testing/staining to render illness/diagnosis

Medical Oncology/Hematology • Clotting disorders • Benign and malignant hematological disease • Benign blood disorders • Chemotherapy • Immunotherapy • Hormonal therapy • Growth factor support • Use of targeted biological agents • Intravenous supportive therapy • Bone marrow biopsy and aspirations

Multidisciplinary Cancer Conferences •

Discussion of cases with an oncology team that includes surgical oncology, medical oncology, radiation oncology, pathology, radiology, nursing, nutrition, palliative care and social services to assure the best possible treatment plan for each patient. Consensus treatment plans are developed.

Oncology Nursing • Monthly educational series • Chemotherapy certified nurses

Pain and Palliative Care •

• •

On-Site dedicated medical team promoting patient and family centered care Home palliative care services Psychosocial services

Pharmacy Services • • • • •

Interdisciplinary approach to oncology patient care TPN and anticoagulation dosing service Antibiotic stewardship program Renal dosing service Pharmacokinetic dosing of aminoglycosides and vancomycin

Radiation Oncology – Community Supported

• CT simulation and treatment planning technology for external beam and HDR brachytherapy • Linear accelerators featuring MultiLeaf Collimation (MLC) and digital portal imaging • 3D conformal radiation therapy • Intensity modulated radiation therapy (IMRT) • Image-guided radiation treatment (IGRT) with on-board imager (OBI) and cone-beam-CT (CBCT)/Brain Lab • High-dose and low-dose rate intracavitary brachytherapy; for Gyn malignancies, interstitial prostate brachytherapy • High dose (HDR) brachytherapy • Accelerated partial breast irradiation (Mammosite, SAVI and 3-D external/IMRT) • Concurrent chemo-radiation therapy • Stereotactic Radiosurgery (SRS) • Stereotactic Ablative Body Radiotherapy (SABR) • Hyperthermia

Support Services • • • • • •

Patient Experience Specialist American Cancer Society Partnership Suncoast Hospice Palliative Care Partnership On-site Cancer Support Group Pet Therapy* Smoking Cessation* *ACS aided service.

Surgical Oncology

• Minimally invasive surgical techniques when appropriate • Lymphatic mapping and sentinel lymph node biopsy for breast cancer and malignant melanoma • Hyperthermic Isolated Limb Perfusion (HILP) • Nipple sparing mastectomy • Radiofrequency ablation • Molecular assay evaluation for breast cancer • Plastics/Reconstruction • Immediate Breast Reconstruction • Bioengineered Breast Reconstruction with A-Cellular Dermal Matrix and Fat Grafting • Oncologic Head and Neck Surgery • Heller Myotomy with Dor Fundoplication

• Microvascular Surgery • Craniofacial Surgery • Colon and Rectal Cancer • Video-Assisted Thoracoscopy • Mediastinoscopy/Mediastinotomy • Esophagectomy • da Vinci Surgical Robotic Technology • Metabolic and Bariatric Surgery

Urologic Oncology/General Adult • •

• • • •

Advanced early detection techniques Minimally invasive surgical procedures as appropriate for both malignancy and benign urologic disorders Cryosurgical ablation Nerve sparing radical cystectomies for prostatectomies Orthotropic reconstructive surgery da Vinci Surgical Robotic Technology

Wound Care and Hyperbaric Medicine • • • • •

Wound Care Therapy Hyperbaric Oxygen Therapy Compression & Edema Management Negative Pressure Therapy Bi-layered Living Skin Substitute Containing Growth Factor’s and Stem Cells

FHNP/USF Partnership

• Surgical Oncology / Pre-Medical Student Summer Internship Program • Nine student participation Peer reviewed journal publications • 2013-14 Colloquium Cancer 101 • USF Research Databases Cutaneous Breast Cancer Screening

17

Breast Health Program Florida Hospital North Pinellas (FHNP) in conjunction with the University of South Florida Department of Surgery and community physicians provide a multidisciplinary approach to the treatment of women diagnosed with breast cancer. FHNP has developed a comprehensive program so that patients have access to the newest treatment modalities and clinical trials in a community hospital setting.

In 2013 over 200,000 new cases of breast cancer will be diagnosed and breast cancer is the highest incidence cancer cared for at the hospital. In 2012 over 100 new cases of breast cancer were registered in the database of the Breast Health Program of FHNP. Screening for breast cancer is an important part of any cancer program. Women will spend 40 or more years having routine annual mammograms. For some women, especially those with family or friends who have experienced breast cancer, this can be a very stressful annual event. The staff of FHNP strive to make the patient’s experience as stress-free as possible. From scheduling to receiving results, a coordinated process is used. At the annual mammogram appointment, a certified mammogram technology specialist will let the patient know what to expect and guide patients through the process. All questions will be answered with the technologist priding herself on being as gentle as possible while still achieving good results. The radiologist will review the mammogram and reports are generated within one to two working days.

About 10% of women will be asked to return. Sometimes the initial mammogram will show something that the radiologist feels needs further evaluation. This return visit may include extra mammogram views or an ultrasound examination to further evaluate an area of potential concern.

During this visit, the radiologist will be working with the mammogram and ultrasound technologists to fully evaluate any areas of concern. At the end of this visit, the radiologist will meet with the patient to discuss the results of these additional tests. Fortunately, approximately 80% of the time, the additional evaluation will indicate that everything looks fine and the patient’s next annual visit can be scheduled. In a few cases, the radiologist may decide that there are findings seen on the mammogram or ultrasound that are concerning enough that a tissue sample is needed to further evaluate the abnormality. In this case, the recommendation will be for a biopsy. Even when a biopsy is recommended, in the majority of cases, the final result will be a benign finding (not cancer).

Along the way, the specialists at FHNP are there to answer your questions and help guide you through the process. The Breast Health Program strives to make the process as stress-free and comfortable as possible.

18

The treatment for breast cancer has gotten more conservative through the years and physician members in the Breast Health Program have led the way in developing and disseminating new techniques to treat

the disease. When women are initially diagnosed with breast cancer the first treatment is surgical. The surgical approach to the disease has become more conservative with lumpectomy replacing the more radical mastectomy in removing the primary tumor in the breast. Lumpectomy refers to removing the breast cancer with a rim of normal breast tissue around it and currently 66% of women in the program elect or are candidates to receive this procedure.

For determining whether the cancer has spread to the most common site of spread, the lymph nodes under the axilla, surgeons now perform the more conservative lymphatic mapping and sentinel lymph node (SLN) biopsy. This is the technique that program leaders helped to develop in the 90s at Moffitt Cancer Center in Tampa. The old treatment involved taking out all the lymph nodes in the axilla. After this procedure about 30% of women develop what is called lymphedema, or swelling of the arm since the arm’s lymph also drains into the axillary nodes, that now have been removed. Since the lymph nodes are gone the lymph backs up in the arm which can affect the patient for the remainder of their life. The old standard procedure, the complete node dissection, removes on average 15-20 nodes. The SLN procedure removes one or two nodes and arm swelling does not occur. In addition the staging (determining whether there is any spread of the breast cancer to the lymph nodes) is more accurate since the pathologist has only one to two nodes to examine and can perform a more detailed examination with more sections and special stains looking for the breast cancer cells in the lymph node. The SLN procedure is a win/win for the patient; less morbidity with the operation and at the same time better staging. It very quickly became the standard of care for the nodal staging of patients with breast cancer and members of the Breast Health Program have taught the technique to surgeons, pathologists and radiologists throughout the world.

With all lumpectomies the remainder of the breast is treated with external beam radiation. This allows the rest of the breast to be preserved and is given to clean up any other areas of disease that may not be detected on mammograms or physical exam. Radiation plays an essential role in breast conservation for pre-invasive and invasive disease. Radiation also decreases local recurrence and improves survival in all breast cancer patients. The radiation is 28 treatments over a six week period of time which proves a little inconvenient for the patient. For this reason the radiation therapy has also gotten more conservative. Radiation oncologists can now treat the area of the breast where the cancer developed through a catheter that is inserted and stays in place for one week. This is called partial breast radiation and takes advantage of the fact that 95% of recurrences of breast cancer occur in the same quadrant of the breast in which the cancer developed. The radiation goes from six

weeks to one week – a tremendous advantage for women. Highly selected women with early stage breast cancer can now receive radiation to the tumor bed twice a day for one week with the same results as whole breast radiation and less side effects. At Florida North Pinellas Hospital this is offered to patients through collaboration of surgeons, medical oncologist and radiation oncologist at the multidisciplinary tumor conference.

In women who have larger tumors or multicentric disease (disease in more than one quadrant or area of the breast) mastectomy may be the only option. In this case all patients receive a pre-operative consultation with plastic surgery in order to discuss the various options for breast reconstruction. With newer surgical approaches for performing the mastectomy, such as the nipple and skin sparing mastectomy procedure, 99% of the breast tissue can be removed with an incision hidden below the breast. The start of reconstruction of the breast mound can begin immediately by insertion of a tissue expander. In this way the cosmetic result is unparalleled despite the need for mastectomy.

Thus the surgical treatment and the radiation therapy in women that are diagnosed with breast cancer have gotten more conservative through the years. But to achieve the best results medical oncology participation is key and the Breast Health Program is fortunate to involve a number of community medical oncologists that have a special interest in treating women diagnosed with breast cancer. In the area of medical oncology, breast cancer care may involve hormonal therapy to block estrogen or progesterone sensitive breast cancers. Through advances in molecular biology one can evaluate breast tumors for their genomic profiles.

These assist in determining which patients have the potential to gain greater benefit from chemotherapy in reducing the risk for later breast cancer recurrence, as well as identifying patients who can be spared the side effects of chemotherapy. Breast cancer chemotherapy is tailored to the patient’s individual tumor characteristics by incorporating the Mammoprint 70-gene assay and the Oncotype 21-gene assay in defining the genetic signature of each cancer. In this way the need for total body treatments such as chemotherapy or hormonal therapy is evaluated and

19

Continued - Breast Health Program individualized to minimize side effects and maximize clinical benefit. In addition women are given the opportunity to participate in life-saving clinical trials that are offered in the community. The MINT trial is one such example that attempts to evaluate the role of gene expression profiling in women with advanced tumors, since it has previously has been shown to be predictive of benefit in patients with earlier stage disease.

Supportive measures to ameliorate the side effects of chemotherapy continue to advance. More and more women are joining the ranks of breast cancer survivors with the help of medical oncology treatments.

People 65 years old or more are the fasting growing segment of the population in the United States. The majority of breast cancers in the US are diagnosed as a result of an abnormal screening study, although a significant number are also first brought to attention by a patient or clinical breast examination. Many elderly patients frequently ask if it is necessary to continue breast cancer screening. Indeed it is still indicated as the incidence of breast cancer, particularly ductal carcinoma in situ (DCIS), increases with age.

Also several randomized trials have shown that the sensitivity of mammography and clinical breast examination is higher in older women.

This is may be due in part to changes in breast tissue with age. The breast becomes easier to examine as a woman ages, with replacement of glandular tissue by fat.

Therefore, careful clinical breast examinations are particularly useful and important in older women. Applicable to all of gerontology, when making decisions on screening, clinical investigation and treatment, it is vital to take into consideration the patient’s life expectancy, medical comorbidities and functional status rather than chronological age alone. In general, breast cancer screening with mammography should be continued as long as a woman has a life expectancy of at least five to seven years. The take-home message should be that age should not be the sole determining factor in determining indications for any screening modality.

cognitive function, nutrition, poly-pharmacy, and geriatric syndromes (dementia, delirium, depression, falls, neglect/abuse, spontaneous bone fractures, incontinence, amongst others).

Aging is commonly accompanied by a decline in the function of critical organ systems; this underlies age-related loss of physiologic reserve. Older patients with little reserve are at risk for decompensation upon exposure to severe stresses such as cancer treatment (chemotherapy in particular).

However, chronologic age does not reliably predict physiologic decline.

Quality of life is a crucial component of decision-making when treating older cancer patients. Most elderly patients are just as willing to try cancer treatment regimens compared to younger persons, however they are less willing to endure the severe treatment-related side-effects. In healthy, fit older adults with minimal co-morbidities and nearnormal functional reserve, aggressive treatment is warranted and can yield results similar to those in younger patient. However, in frail older adults with multiple co-morbidities and significant functional impairment, disease management should focus on quality of life and symptom palliation, rather than prolonging survival. Palliation focuses on preventing and relieving suffering and supporting the best possible quality of life for patients and their families facing serious illness.

The majority of breast cancers in the US are diagnosed as a result of an abnormal screening study, although a significant number are also first brought to attention by a patient or clinician breast examination.

20

In elderly patients diagnosed with cancer, a comprehensive geriatric assessment is critical in formulating an appropriate, individualized treatment plan. Treatment decisions need to consider both the patient’s overall status and potential differences in the natural history of the disease. It is especially important that the elderly have an interdisciplinary management approach. A comprehensive geriatric assessment aids in treatment decision-making by addressing several domains: physical function, co-morbid conditions, psychological state, social support,

Florida Hospital North Pinellas (FHNP) offers genetic counseling and testing for a variety of cancers through our community medical oncologists as well as through the University of South Florida (USF). Cancer Genetic Counseling is an important part of FHNP’s commitment to providing world-class oncology services. This program serves individuals who are at increased risk for hereditary cancer.

Patients and families with many different types of cancers, including breast, ovarian and colon cancer are seen. Cancer Genetic Counseling is an excellent example of FHNP’s dedication to personalized medicine.

Through advanced techniques such as genomics, the physicians in the Breast Health Program are optimizing the health of each patient by calculating their risk of developing a cancer. If patients are identified to be at an increased risk, prophylactic surgery or medical treatment may be indicated to lessen their risk. As a board-certified medical oncologist with experience in genetic testing and counseling, Gail Wright, MD, continues to provide genetic counseling and testing to appropriate patients. Dr. Wright trained at the National Cancer Institute in Bethesda, Maryland with the Family Studies Section of the Cancer Epidemiology Program. She then subsequently initiated and directed the cancer genetics screening program at the Lifetime Cancer Screening Center at Moffitt

Cancer Center, in Tampa, Florida. While at Moffitt she recruited Rebecca Sutphen, MD, a Medical Geneticist, to oversee the genetic counseling and testing program. While practicing in the New Port Richey community, Dr. Wright continues to offer cancer genetics counseling and testing to patients at Florida Cancer Specialists and Research Institute. Rebecca Sutphen, MD, FACMG, is a board-certified clinical and molecular geneticist with expertise in hereditary cancer. She is an active researcher and professor in the Epidemiology Center, Department of Pediatrics, USF Morsani College of Medicine. Dr. Sutphen and her staff at the University of South Florida offer genetic counseling and testing to those patients and their families identified to be at high risk who may want a second opinion.

One of the special features of the Breast Health Program is the presence of an electronic medical record (EMR) database that is used on a daily basis to take care of patients. Some features of the database are as follows: (1) summarizes the entire chart into a single page of the most critical elements for the patient to streamline clinic visits, (2) over 100 variables are collected for each patient in the database that can then be queried for research projects to define the prognosis and natural history of many of the breast cancer populations, (3) efficient clinical trial eligibility determination and (4) universal access to all the clinical information on any patient at the fingertips of members of the Program.

The physicians of the Breast Health Program are excited to be part of the expansion of the “Operation Sunshine,” Program that will eventually lead to breast cancer screening and early detection programs in Pinellas County. Funding for the program will be provided by the “Doctor Idol” Event of the FHNP Foundation. This is the major fundraiser for FHNP and the Breast Health Program is grateful for the support that in turn will allow the program to offer a community service not available at this time. For this ground breaking program for the Adventist Health System, a mobile van, generously donated by Sun Toyota, will travel throughout the county to schools and industry to perform on-site education about breast cancer screening. In this way, employees do not have to take self-time to receive these services for the early detection that may in turn be life-saving. Participants will be queried about their breast cancer screening activities and if lacking will be offered appointments at FHNP for mammograms and clinical exams. There exists plenty of scientific evidence that screening for breast cancer can result in early detection and better prognosis for the patient Members of the Breast Health Program also participated in the summer internship program designed for undergraduate and nurse practitioner students interested in a medical career. Nine students from University of Florida, Florida State, University of South Florida, Boston College and Bucknell University participated in a month long shadowing program

rotating through the surgical, radiology, pathology, nutrition, urology, primary care, ENT and medical and radiation oncology departments and programs of the hospital last year and this year nine students have enrolled. Highlights of the program include the ability of the students to scrub-in to operations to first assist in the procedure, participating in daily conferences and writing case reports of interesting patients. This allows the student to get published which may be a distinguishing factor in their applications to medical school or other graduate programs. The students also had the opportunity to attend the annual meeting of the Society of Surgical Oncology and present their research with a poster presentation.

Space for a dedicated Women’s Center was renovated and opened offering women much more privacy as their abnormal mammograms are investigated. Digital mammography has been introduced that improves the resolution of images and enhances tumor characterization to help promote early detection compared to the old film standard. Through the hospital PACs system digital images are available in the Surgical Institute when the patients are seen in the clinic for follow-up. With same day appointments for their digital mammograms and clinic appointments, one stop shopping is offered for patient convenience. In addition, the Breast Health Program now offers patients breast MRI that is even more sensitive than digital mammography in identifying abnormalities particularly in younger women with dense breasts.

Staging is an important part of caring for the patient with cancer during the follow-up period. In this way recurrences are detected early when therapy may be possible and the effect of various treatments may be evaluated and monitored. A mobile PET/CT scanner is available on campus to offer this important service. The PET/CT scanner has replaced the CT scans and bone scans from the past and is the preferred method to stage cancer patients in follow-up clinics.

The future is bright for the Breast Health Program at FHNP as we strive to deliver cutting-edge care and resources to patients in Pinellas County and throughout the state of Florida.

Respectfully submitted, Rosemary Giuliano, ARNP – Director, Oncology Vivian Griffin, MD – Radiation Oncology Douglas Reintgen, MD – Professor of Surgery, Surgical Oncology Cynthia Roever, MD – Geriatric Medicine Debra Schneider, MD – Radiology Gail Wright, MD – Medical Oncology 21

Melanoma & Cutaneous Oncology Program The Cutaneous Oncology Program (COP) at Florida Hospital North Pinellas is one of the largest referral centers for patients with melanoma in the state of Florida. Melanoma and other skin cancers like Basel Cell Carcinomas (BCC) and Squamous Cell Carcinomas (SCC) are epidemic in the state of Florida due to the intense sun light exposure and the elderly population. From Cancer USA 2013 numbers there will be 2.1 million skin cancers diagnosed in the United States, while all other cancers combined number 1.5 million. Melanoma is one of the highest incidence of cancers being cared for in the Surgical Institute and at FHNP. In the 2012 calendar year the Cutaneous Oncology Program registered over 220 new patients. Malignant melanoma, the most dangerous skin cancer, causes one death in the United States every hour. In 2013 there will be 9,480 melanoma patients die, while deaths from other skin cancers, predominantly SCC are another 3,170 patients. Fortunately if melanoma and SCC are found in the early stages when they are superficial, their cure rate can approach 95%. In the United States in 2013 invasive melanomas will account for 76,690 cases while in-situ or early melanomas number 61,300 more. Therefore 50% of all melanomas are potentially dangerous and life threatening. Of particular concern is that young Caucasian women are having an annual increase of melanoma of 3.8% and Caucasian men over 65 are having a 8.8% annual increase. According to the American Cancer Society the five-year survival rate of early melanoma is approximately 98% when confined to the superficial skin, but decreases to 62% at five years if lymph nodes are involved and only 5% if internal organs become involved with disease.

The COP focuses on the following key issues: 1) patient education and prevention, 2) diagnosis, 3) surgical treatment of cancer, 4) treatment of advanced diseases, 5) clinical research and healthcare outcomes. Patient education and prevention is essential to offer as a community service. It is exciting to think that with guidance from the Cutaneous Oncology Program, the patient is able to directly improve their skin health and decrease their chance of skin cancer by simple changes in their lifestyle.

Minimizing risk factors, particularly involving too much sun exposure, has been well-documented. Every patient is given information of when and how to apply sunscreen and which ones are most effective. Other simple ways to prevent skin cancer include protective clothing and avoiding severe sunburns. The COP also emphasizes school education. Currently tanning bed usage by teenage girls at 18 years old is 40%. Many are under the impression that because a tan does not burn it is safe, which is incorrect. In fact, there is a significant association of melanoma risks and ultraviolet UV emitting tanning beds.

22

As with any cancer, cure is a possibility with early detection of the most serious skin cancer, melanoma. The lay public and primary care physicians

should know the pattern of moles, blemishes, freckles, and other marks on your skin so that changes in existing moles can be identified. Any unusual sore, lump, blemish, marking, or change in the way an area of the skin looks or feels may be a sign of skin cancer or a warning that it might occur. The most important warning sign for melanoma is a new spot on the skin or a spot that is changing in size, shape, or color. The ABCDE rule is another guide to the early diagnosis of melanoma. People should be on the lookout and tell their doctor about spots that have any of the following features: A is for Asymmetry: One half of a mole or birthmark does not match the other, B is for Border: The edges are irregular, ragged, notched, or blurred. C is for Color: The color is not the same all over and may include shades of brown or black, or sometimes with patches of pink, red, white, or blue. D is for Diameter: The spot is larger than 6 millimeters across (about Ÿ inch – the size of a pencil eraser), although melanomas can sometimes be smaller than this. E is for Evolving: The mole is changing in size, shape, or color or may be weeping or bleeding.

Multidisciplinary care is a hallmark of the COP since many times dermatologic, surgical, medical and radiation oncology specialties are needed to give the patient the best chance of cure. This is achieved through the monthly Tumor Board where interesting or controversial cases are discussed and a consensus is developed as to the best way to treat the patient. Clinical research protocol eligibility is also determined for each patient presented at the conference. A mix of employed FHNP physicians, community physicians and doctors from the University of South Florida provide input at the conference to develop the consensus.

Unique procedures available in the program include lymphatic mapping and sentinel node biopsy techniques for the nodal staging of newly diagnosed melanoma. In fact, Douglas Reintgen, MD and members of his team were part of the group to help develop this procedure in the ‘90s when he was the program leader of Cutaneous Oncology at Moffitt Cancer Center, eventually teaching the technique to over 3000 physicians worldwide. This surgery is a win/win situation for the patient resulting in a less morbidity from the operation and more accurate staging by the pathologist. Very quickly it became the standard of care for patients with melanoma and women with breast cancer.

Another unique surgical procedure offered at FHNP is the hyperthermic isolated limb perfusion technique for patients with recurrent melanoma confined to either the upper or lower extremity. In this technique the circulation of the extremity is isolated from the rest of the body and just the affected extremity is treated with high doses of chemotherapy and high temperatures. Patients achieve a complete response rate of 70% with this surgical technique, a rate that is unmatched with most treatments for

cancer. FHNP is the only hospital in the state of Florida that offers this technically demanding procedure.

Two new drugs have been approved by the FDA this year for the treatment of Stage IV melanoma, ipilimumab and vermuafenib that can give objective response rates of 30-40% in appropriate patients. This response rate compares favorably to other total body (systemic) therapies for melanoma that are used when the disease spreads internally. With the older compounds response rates in the 10% range were obtain, a low figure considering the toxicity of the chemotherapy. Sometimes more than one type of treatment is used which may include surgery, immunotherapy (Interferon, Il-2, CTLA4 inhibitor, PD1, and PD-L1 inhibitor) targeted therapy (BRAF inhibitors, MEK inhibitors and C-kit targeting drugs) and radiation therapy. With evolving techniques of molecular profiling of the cancer cells many of the previously poor prognostic melanomas can be treated with targeted therapies achieving dramatic responses.

leaves little to no scarring and is in many cases cosmetically superior to surgery. Patients with large skin cancers of other sites not surgically resectable are often referred for radiation therapy. In our community, multiple radiation therapy techniques are available to treat skin cancers that range from simple to highly complex. External radiation with photon or electron beam, as well as high dose rate brachytherapy techniques are used to treat some of the most complex cases such as the entire scalp or hands without having to travel out of the area for special treatment.

Two new drugs have been approved by the FDA this year for the treatment of Stage IV melanoma, ipilimumab and vermuafenib that can give objective response rates of 30-40% in appropriate patients.

Radiation therapy is offered in the community setting for patients diagnosed with both melanoma and non-melanoma skin cancers. Patients with melanoma who have undergone surgical resection and appropriate lymph node evaluation are offered adjuvant radiation therapy based on several factors related to their primary disease stage and location. Radiation therapy is recommended to patients who have close or positive surgical margins or special types of primary melanoma, like desmoplastic melanoma. In patients who have positive lymph node involvement, treatment with radiation is offered as well depending on the number of nodes involved as well as when the metastatic disease invades outside the lymph node capsule into the surrounding fat. Adding radiation therapy when lymph nodes are involved reduces the recurrence rate after surgery.

Radiation therapy alone is indicated for control of melanoma skin cancer in situations where surgery is unable to be performed due to large advanced disease.

Common skin cancers, basal and squamous type, are treated in the community with a variety of techniques. Radiation therapy is offered as primary and adjuvant therapy for patients with skin cancer. Typically this is recommended for primary and recurrent lesions of the central face, especially the eyelids, nose, and lips. Large lesions on the ears, forehead and scalp are often treated this way as well. This type of treatment often

Staging is an important part of caring for the patient with cancer during the follow-up period.

In this way recurrences are detected early when therapy may be possible and the effect of various treatments may be evaluated and monitored. A mobile PET/CT scanner has become available to offer this important service on site at FHNP. The PET/CT scanner has replaced the CT scans and bone scans from the past and is the preferred method to stage cancer patients in follow-up clinics.

One of the special features of the Cutaneous Oncology Program is the presence of an electronic medical record (EMR) database that is used on a daily basis to take care of patients. Some features of the database are as follows: (1) summarizes the entire chart into a single page of the most critical elements for the patient to streamline clinic visits, (2) over 100 variables are collected for each patient in the database that can then be queried for research projects to define the prognosis and natural history of many of the melanoma populations, (3) efficient clinical trial eligibility determination and (4) universal access to all the clinical information on any patient at the fingertips of members of the Program.

Difficult to treat SCC and BCC of the skin, due to size or location, are also specialties of the clinic. Other skin cancers besides melanoma are also epidemic in the state of Florida and most of these cancers occur on the sun exposed areas of the body, such as the arms, hands and face. Removing the entire cancer and obtaining clear margins but also preserving function with the best cosmetic results are two goals of the clinic for these patients. Major resections including head and neck skin cancers are performed with immediate reconstruction by plastic surgery securing the best cosmetic result.

23

Continued - Melanoma & Cutaneous Oncology Program As mentioned during this past year the physicians and nurse practitioners of the Cutaneous Oncology Program began “Operation Sunshine,” an education and skin cancer screening program for schools and industry in Pinellas County. Funding for the program is provided by the “Doctor Idol” Event of the FHNP Foundation. This is the major fundraiser for FHNP and the COP is grateful for the support that in turn will allow the program to offer a community service not previously available. For this ground breaking program for the Adventist Health System, a mobile van, generously donated by Sun Toyota, is traveling throughout the county to schools and industry to perform on-site education and skin cancer screening. In this way, employees do not have to take self-time to receive these services for the early detection of skin cancers that may in turn be life-saving. Grade school and teenage participants will learn about sensible sun safety techniques with age-appropriate teaching material. There exists plenty of scientific evidence that if you can diagnosis melanoma early when it is “thin,” it is curable. Eventually this program will expand into other cancer screenings for lung, breast, colon, cervical and prostate cancers.

Members of the COP also participated in the summer internship program designed for undergraduate and physician extender students interested in a medical career. Nine students from University of Florida, Florida State, University of South Florida and Southeastern College participated in a month long shadowing program this past summer. Students rotate through the Surgical, Radiology, Pathology, Nutrition, ENT, Family Practice, Ob/Gyn, Urology and Medical and Radiation Oncology departments and programs of the hospital. Highlights of the program include the ability of the students to scrub-in to operations to first assist in the procedure, participate in daily conferences and write case reports of interesting patients. This allows the student to get published which may be a distinguishing factor in their applications to medical school or other graduate schools. The last group of students published the following paper in Annals of Surgical Oncology and presented the paper at the annual meeting of the Society of Surgical Oncology: Reintgen M, Murray L, Akman K, Giuliano R, Loznicki A, Shivers S, Reintgen DS. Evidence for a better nodal staging system for melanoma: The clinical relevance of metastatic disease confined to the sentinel lymph nodes. Ann Surg Oncol 20:668-674, 2013.

24

The team has been invited to the next meeting of the American joint Committee on Cancer Melanoma Staging Committee to present the data to determine whether the international staging system for melanoma should be changed based on the findings of the paper. This is certainly an exciting development.

The future is bright for the Cutaneous Oncology Program at FHNP as we strive to deliver cutting-edge care and resources to patients in Pinellas County and throughout the State of Florida.

Sincerely yours, Uday Dandamudi, MD – Medical Oncology Rosemary Giuliano, ARNP – Director, Oncology Program Richard Hamill, MD – Dermatology Lawrence Hochman, DO – Radiation Oncology Douglas Reintgen, MD – Professor of Surgery, Surgical Oncology

25

Gastrointestinal Oncology Program The Florida Hospital North Pinellas (FHNP) Gastrointestinal (GI) Oncology Program has a dedicated staff focused on cancer of the esophagus, stomach, bile ducts, liver, pancreas, colon, rectum and anus.

The program is based on a multi-specialty team approach. In this way, each patient’s care is coordinated with expert input from all the cancer specialties creating a personalized treatment plan for each patient. Our multidisciplinary approach is like getting multiple second opinions in one setting. All of the physicians treating gastrointestinal cancer meet to review the cases at a monthly conference. This includes the surgical oncologist, medical oncologist, radiation oncologist, pathologist, radiologist, nurse practitioner and clinical trials staff. We believe it is critical for all the FHNP cancer physicians to discuss the patient’s care before starting treatment. This assures the best, safest and individualized approach for each patient, as cancers are not all alike. The oncology team is committed to fighting cancer and all of the members have completed specialized training for the care of patients with cancer.

Work up and evaluation of such patients include a detailed history and physical examination, blood work, imaging (CT and PET scans) as well as endorectal ultrasound for cases of rectal cancer. Once the determination of disease extent is made, an appropriate treatment regime can be outlined.

The lymph nodes are typically the first place colorectal cancer will spread.

One of the critical steps in the surgical resection of the tumor is making sure enough lymph nodes have been surgically removed to be examined by the pathologist. The surgical technique including lymph node sampling is a major focus of the surgical team at FHNP. Many studies have shown that having the appropriate surgical procedure can have a dramatic effect on someone’s chance of cure in GI cancer.

Undergoing colorectal cancer screening has been shown to significantly decrease the likelihood of dying from this disease and allow these tumors to be identified at an early stage when they have an excellent chance of cure with surgery alone.

Colorectal cancer is the most common GI malignancy and the third most common cancer in men and women. There are approximately 40,000 new cases of rectal cancer each year in the United States and accounts for approximately 10 percent of all cancer deaths. One in 17 individuals will develop colorectal cancer. If diagnosed with colorectal cancer, your chance of dying from this disease is much higher than patients with a diagnosis of breast or prostate cancer. This is in spite of the fact that colorectal cancer can be detected early with routine screening and also be prevented in most cases by colonoscopy and removal of polyps before they develop into cancer.

26

All men and women beginning at age 50 should be screened for colorectal cancer (screening should begin earlier in certain situations including when there is a family history of colon or rectal cancer). Undergoing colorectal cancer screening has been shown to significantly decrease the likelihood of dying from this disease and allow these tumors to be identified at an early stage when they have an excellent chance of cure with surgery alone. Despite these figures, only approximately 40 percent of the eligible US population is screened for colorectal cancer. The GI oncology program at FHNP offers colorectal cancer screening and educational programs designed to inform our community about the need and benefits of colorectal cancer screening.

Beyond the lymph nodes, colorectal cancer frequently spreads to the liver or lungs.

With new and effective chemotherapies, response rates and survival for these tumors is dramatically increased from what it was just a few years ago. A multimodality approach is commonly utilized, including surgery and chemo-radiation therapy.

For rectal malignancies that are confined to the bowel wall without lymph node involvement, surgery is typically performed first, followed by postoperative chemoradiation therapy as needed depending upon the pathologic findings. For very early tumors with favorable features, a transanal excision may suffice. In addition, chemoradiation therapy has a critical role in the preservation of the anal sphincter when there is a low lying rectal cancer. In such a situation, preoperative treatment often times decreases the tumor volume to such an extent so as to allow a sphincter-preserving operation that would otherwise not be possible.

As a colorectal cancer gets close to the anus, the concern for a permanent colostomy bag becomes more likely. The GI oncology program at FHNP is committed to sphincter preservation. We utilize a number of methods for this goal including treating the tumor first with radiation and chemotherapy to shrink it.

Even if the colorectal cancer has spread to the liver or lungs, cure may be possible with chemotherapy, surgery, and radiation. That is why bringing together specialists from surgical oncology, medical oncology and

radiation oncology is essential in the treatment of each cancer to develop a personalized treatment plan. Just as every person is different, no two GI cancers are the same. That is why a multidisciplinary approach to each cancer will give the patient a better chance of cure and survival.

One of the proud distinctions of the FHNP GI Oncology Program is the addition of the da Vinci Robotic Surgery Program. This technology affords all the advancements of minimally invasive surgery, but adds precision, speedier recovery, and decreased pain to the armamentarium. Patients who are candidates for minimally invasive surgery may have their surgery performed robotically, with the surgeon seated at the console controlling every movement of the robotic arms. This is on the cutting edge of surgical technology, and FHNP boasts several surgeons who are certified to perform colorectal surgery utilizing the da Vinci surgery system.

Finally, much progress has been made in the treatment of rectal cancer, translating into better patient outcomes. Future directions include improved radiation therapy planning and administration as well as new targeted therapies.

Sincerely, Keith G. Chisholm, MD, FACS – General Surgery Raj P. Kotak, MD, FACS – General Surgery Arthur Matzkowitz, MD – Radiation Oncology Lourdes Santiago, MD, FACS – General Surgery

27

Thoracic Oncology Program The American Cancer Society estimates 228,190 people in the United States will be diagnosed with lung cancer in 2013. Approximately 159,480 people will die from lung cancer in 2013, making this the most deadly form of cancer by far. Each year, more people die from lung cancer than colon, breast, prostate, and pancreatic cancer combined.

Despite these statistics, some people can be cured from lung cancer. For those diagnosed with lung cancer between the years 1998 and 2000, the five years survival rates in stages 1A and 1B are approximately 49% and 45%, respectively.

Recent data suggests that screening people at risk with CT scans can not only diagnose patients at an earlier stage, but improve overall survival. Recent data from the National Lung Screening Trial showed that screening people at higher risk for developing lung cancer with low dose CT scans can reduce one’s risk from dying from lung cancer by approximately 20%. People that were included in this study deemed to be at significant risk for developing lung cancer were between the ages of 55 and 74, smoked for at least 30 pack-years (pack/day for 30 years), and had to have smoked within the last 15 years. Those people were screened by annual CT scans of the chest for 2 years. People diagnosed with lung cancer in this trial tended to be at an earlier stage than those not in the trial, and therefore translated to improved survival.

Florida Hospital North Pinellas is currently developing a screening program that will be offering patients at risk an opportunity to get screened for a nominal fee.

significantly less pain after surgery and much quicker recovery. It also leads to fewer complications after lung surgery. It can also potentially translate to better long term outcomes from a cancer standpoint as patients that require adjuvant chemotherapy can receive it sooner and are more likely to tolerate it better.

We have also partnered with several oncology groups with expertise in delivering the most up to date chemotherapy regimens as well as participating in clinical trials. Surgeons, medical oncologists, and radiation oncologists work together to deliver treatment on an individualized basis. Sometimes patients may receive a combination of surgery, chemotherapy, and radiation therapy. Recent advances in chemotherapies have allowed for more effective regimens with fewer side effects. Along with surgery and radiation therapy, systemic therapy plays a significant role in the management of lung cancer. Traditionally, chemotherapy was the only route that was available for the medical oncologist to treat more advanced lung cancer. However, over the past several years we have learned a great deal more about the biology of lung cancer. With this increased knowledge we have seen the development of new “targeted” agents that work directly on certain mutations that can be present in lung cancers.

These new “targeted” agents are not chemotherapy, and therefore are not associated with the side effects that traditional chemotherapy has been known to have. There have already been several agents approved by the FDA, with several more currently in late stage clinical trials. Traditional chemotherapy still plays a significant role in treating advanced lung cancer, however, as we move forward we will continue to develop more “targeted” agents as we move into the era of personalized medicine for cancer patients.

Improving care and outcomes for patients with lung cancer and other thoracic malignancies is the committed objective of the FHNP Thoracic Oncology Program (TOP).

Florida Hospital North Pinellas (FHNP) has placed a strong emphasis on cancer treatment. Improving care and outcomes for patients with lung cancer and other thoracic malignancies is the committed objective of the FHNP Thoracic Oncology Program (TOP). Working in a multidisciplinary and collaborative approach, the TOP team is a specialized group of healthcare professionals who are dedicated to preventing, diagnosing, treating and managing lung cancer and esophageal, pleural, mediastinal and chest wall tumors.

28

Surgery continues to play the most important role in the potential cure for lung cancer. At FHNP most patients that are surgical candidates can be treated via a minimally invasive approach known as VAT Lobectomy.

In this approach, the surgery is done with small incisions, using cameras and without any retractors that spread the ribs. This results in

Advances in technology have also allowed for more effective ways of delivering radiation treatments with fewer side effects. There has been many advances in the field of Radiation Oncology in the last 1015 years. New technologies include Intensity Modulated Radiation therapy (IMRT), Image Guided Radiation Therapy( IGRT), Stereotactic Body Radiosurgery (SBRT) and increase utilization of High Dose Brachytherapy (HDR). Lung Cancer in the past was associated with dismal outcomes, more so in surgically unresectable or medically compromised patients. Now with Stereotactic Body Radiosurgery (SBRT) patient with Stage I/II medically inoperable NSCLC can receive this therapy. SBRT is a non-surgical therapy that uses elements

of 3-Dimensional conformal therapy, IMRT, IGRT and stereotactic targeting to allow dramatic reduction in target volumes and dose escalation.

Clinical trials have shown 95% local control with Stage I patients. Disease-free survival of 71% for Stage I patients at five years have been reported and confirmed in multiple trials. SBRT is delivered twice a week for three to four treatments. Florida North Pinellas Hospital lung patients are discussed at Multidisciplinary Tumor Board in collaboration with cardiothoracic surgeons, medical and radiation oncologist. These tools have also allowed us to treat more patients that would have otherwise not been candidates for treatment.

To help determine which treatment will lead to the best outcomes, staging is critical. FHNP is now able to offer fusion PET/CT scans to allow for more accurate radiologic staging. Liberal use of video mediastinoscopy to sample lymph nodes also allows us to accurately stage patients.

Most sincerely, Louis Astra, MD – Thoracic Surgery Katherine Fondren, ARNP – Surgical Hospitalist Vivian Griffin, MD – Radiation Oncology David Wenk, MD – Medical Oncology

29

Head & Neck Program According to the National Cancer Institute, approximately 52,000 men and women in the United States will be diagnosed with head and neck cancers this year. This represents about three to five percent of all cancers diagnosed. Head and neck cancers include tumors of the larynx, oral cavity, pharynx, thyroid and parathyroid glands, salivary glands and paranasal sinuses.

CS A F , , MD gery , os ur rri ck S y e B g se & Negolo o J ad yn He olar Ot

Surgery is the first line of defense in the treatment of cancers of the head and neck. At Florida Hospital North Pinellas (FHNP), utilizing state-of-the art diagnostic and surgical equipment the surgeon is able to diagnose, stage and treat the patient. While some patients respond best to surgical treatment others require a multi-disciplinary approach. For this reason, at FHNP patients with all types and stages of head and neck cancer are treated with a comprehensive approach including surgery, chemotherapy and radiation therapy. The head and neck surgeon works in concert with the medical and radiation oncologist to develop a treatment plan tailored to the individual needs of the patient with the goal of achieving the optimal outcome and decreasing the risk of recurrence. Additionally, speech-language pathologists, nutritionists and respiratory therapists play a valuable role in the successful treatment of the patient with head and neck cancer with their ultimate goal being to keep the patient’s ability to talk, eat and breathe as normal as possible. The health care team at FHNP makes every effort to help the patient return to regular activities as soon as possible.

Common skin cancers, basal and squamous type, are treated in the community with a variety of techniques. Radiation therapy is offered as primary and adjuvant therapy for patients with skin cancer. Typically this is recommended for primary and recurrent lesions of the central face, especially the eyelids, nose, and lips. Large lesions on the ears, forehead and scalp are often treated this way as well. This type of treatment often leaves little to no scarring and is in many cases cosmetically superior.

Patients with large skin cancers of other sites not surgically treatable are often referred for radiation therapy. In our community, multiple radiation therapy techniques are available to treat skin cancers that range from simple to highly complex. External radiation with photon or electron beam, as well as high dose rate brachytherapy techniques are used to treat some of the most complex cases such as the entire scalp or hands without having to travel out of the area for special treatment.

Sincerely, Jose Berrios, MD, FACS Head & Neck Surgery, Otolaryngology Gulf Coast Ear, Nose & Throat  

30

Urologic Oncology & General Urology The Urologic Oncology program at Florida Hospital North Pinellas (FHNP) evaluates a broad range of patients with urologic problems for both men and women. Services include not only urologic oncology, but also general adult urology.

FHNP has pioneered the use of cryosurgical ablation of prostate and kidney tumors in our area.

Cryosurgical ablation includes a shortened recovery time, a lower risk of potential side effects and a quicker return to normal daily activities.

Pa Ur ul M olo . A gic rno Open and laparoscopic nephrectomies, radical cystectomy with bladder reconstructive surgery for patients Su ld, rg MD with advance bladder cancer, open and perineal prostatectomy for prostate cancer all offered at FHNP. Full radiation ery , F therapy services are available in the community including image-guided RT (IGGRT with SonArray ultrasound guidance AC S combined with IMRT), and permanent radioactive seed implant (brachy therapy) for prostate cancer.

Also, with the addition of the da Vinci Robotic Surgery Program at FHNP, patients can expect an approach that offers the benefits of minimally invasive surgery, in addition to advanced precision, speedier recover and decreased pain. Our Robotic Surgery program at FHNP currently benefits from the skill of three urologists trained in robotic surgery.

Our physicians and staff also offer evaluation as well as medical and surgical treatment for patients with impotence, urinary incontinence, stone disease, and urinary tract infections. FHNP offers minimally invasive treatment options for benign prostatic hyperplasia that offers the same results of traditional TURP without the bothersome side effects since this minimally invasive technique uses a laser to vaporize tissue, creating a channel through which men can urinate more freely.

• The Holimium 100 watt laser, Bipolar Button Vaporization and Bipolar TURP and the • The Greenlight XPS Laser which, • Dr Arnold is internationally recognized and certified as an instructor in this technique.

• The Protouch 1470 laser where FHNP is one of only five centers in the US offering this therapy and: • Its 1470 nm wavelength is highly absorbed by both water and hemoglobin making it ideal for ablating soft tissue. As the laser energy ablates tissue, it simultaneously seals off the blood vessels to minimize bleeding. This system allows the surgeon to operate in contact mode, which provides the tactile feel of a scalpel or electrode loop without destroying the fiber.

The urologists at FHNP work side-by-side with their colleagues in medical and radiation oncology, providing comprehensive and integrated cancer care for our patients. In addition, monthly cancer conferences are held to review treatment plans for our patients allowing us the ability to obtain state-of-the-art treatment recommendations from a multidisciplinary panel of physicians and providers.

We strive to provide precision-oriented, accurate care and up-to-date information to patients regarding the treatment of various cancers as well as methods of rehabilitation from treatment-related side effects. All available treatment options are presented to the patient so they can make informed decisions. Treatment plans are addressed from an individual perspective, and an appropriate approach to treatment is taken with each patient.

Sincerely, Paul M. Arnold, MD, FACS Urologic Surgery Urology Specialists of West Florida 31

Plastic & Reconstructive Surgery

S BP A , CS ery A F , rg MDve Su , s i liti ruct o P t as cons p p e a e Pc & R i f Ef asti Pl

It is estimated that more than 20 million cosmetic and reconstructive procedures are performed by plastic surgeons every year. Both cosmetic and reconstructive surgery help patients of all ages and types whether it’s a female with symptoms of enlarged breasts, a child with a birth defect, a young adult injured in an accident, or an adult with a cancer diagnosis. Each year plastic and reconstructive surgeons improve the lives of millions of patients with congenital malformations (such as cleft lip and cleft palate), disfiguring wounds, animal bites, and profound burn injuries, as well as those requiring reconstruction after surgery for malignancy or other chronic conditions.

Plastic surgery deals with the repair, reconstruction, or replacement of physical defects of form or function involving the skin, musculoskeletal system, craniomaxillofacial structures, hand, extremities, breast and trunk, external genitalia or cosmetic enhancement of these areas of the body. Special knowledge and skill in the design and surgery of grafts, flaps, free tissue transfer and replantation is necessary. Competence in the management of complex wounds, the use of implantable materials, and in tumor surgery is required. Cosmetic surgery is an essential component of plastic surgery. The plastic surgeon uses cosmetic surgical principles both to improve overall appearance and to optimize the outcome of reconstructive procedures. The goals of reconstructive surgery differ from those of cosmetic surgery. Reconstructive surgery is performed on abnormal structures of the body, caused by birth defects, developmental abnormalities, trauma or injury, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. On the other hand cosmetic surgery is performed to reshape normal structures of the body to improve the patient’s appearance and self-esteem.

At FHNP we believe the multidisciplinary team approach ensures that each patient has the best opportunity for a successful outcome regardless of how small or complex the procedure may be.

The team at Florida Hospital North Pinellas (FHNP) understands the physical and emotional suffering one goes through when they have been diagnosed with a cancer, lost physical attributes due to a traumatic injury, or are born with a congenital deformity. The field of reconstructive surgery has advanced with incredible speed over the past few decades. It is now possible to restore function and improve the overall appearance through an array of surgical reconstruction procedures that can enhance ones self-esteem especially after undergoing a cancer operation.

At FHNP we believe the multidisciplinary team approach ensures that each patient has the best opportunity for a successful outcome regardless of how small or complex the procedure may be. This is achieved by holding multidisciplinary clinics where the various surgical specialists such as surgical oncology, thoracic surgery, general surgery and plastic/reconstructive surgery are able to see patients in the same clinical setting allowing for patients to be seen on the same day for an expert consensus opinion. This one-stop-shopping approach is a tremendous advantage for patients.

32

The mastery of cutting-edge plastic surgery technologies, the provision of compassionate and confidential care and the pursuit of clinical excellence defines our program’s philosophy. As an academic based practice, our physician group is recognized as leaders in innovation, education and research, which impact clinical outcomes. Clinical research projects are performed with students to better define the natural history of various patient populations and determine outcomes of new surgical techniques and therapies.

Some of the state-of-the-art procedures offered at FHNP include Microvascular Surgery, Bioengineered Breast Reconstruction with flaps, implants and acellular tissue matrices; composite tissue transplantation, Craniofacial Surgery, Maxillofacial and Extremity Trauma Surgery, Oncologic Head and Neck Surgery with reconstruction as well as fat-grafting and body contouring and scar revisions. We also offer Aesthetic and Rejuvenating procedures that include injections to smooth out aging wrinkles and fillers to do the same. The recent advancements in technology better address the needs of patients and allow physicians to improve the delivery of medical care. The future of plastic surgery is filled with exciting promise and creativity, helping to restore form and function while also improving patient safety and the quality of care.

Sincerely, Effie Pappas Politis, MD, FACS, ABPS Plastic and Reconstructive Surgery Florida Hospital North Pinellas Physician Group USF Assistant Professor Division of Plastic & Reconstructive Surgery

33

Cancer Screening Program Florida Hospital North Pinellas’ (FHNP) Screening Program was developed to provide a community service for people to decrease the mortality of cancer through early detection, risk assessment and education. This program uses state-of-the-art technology, equipment, a highly skilled, dedicated staff and reports to the Commission on Cancer committee.

The purpose of cancer screening is to detect cancer before it is clinically apparent, early in its natural history before it has become systemic and spreads internally. Early detection can result in more effective treatment that may be less of a cost for the health care system. An abnormal screening test in this situation leads to further diagnostic evaluation, including other diagnostic tests or biopsy to determine if cancer is present, and to subsequent treatment if cancer is detected.

Expected benefits of screening are reduction in the death rate from the targeted cancer, reduced morbidity from the disease, and reduced health care costs. In addition with an earlier return to work and a productive life, there is less of a cost to the community.

For this reason the support of any cancer screening program must take the long term view of a community’s health, since apparent benefits to the population may not be available for years after institution of cancer screening. Studies have shown that up to 75% of health care dollars are spent in the last years of life, prolonging the inevitable death of the patient when it is largely a hopeless situation.

Perhaps these dollars should be spent up-front, preventing the cancers and diagnosing them early when they are curable with simple surgical techniques. Additional benefits of cancer screening include improved length and quality of life, reduced pain, anxiety and disability.

recommendations adhere to the American Cancer Society and National Osteoporosis Foundations guidelines to identify populations at risk and are appropriate to screen. In addition, mobile screening services are an effective way to increase public awareness with education and to reach out to the under-served population.

For those who are at high risk for developing cancer due to family history or other risk factors, the FHNP Screening Program provides education, cancer prevention strategies, and surveillance plans for early detection.

Genetic screening services such as counseling and genetic testing are available for individuals who are at risk for breast and/or ovarian cancer, colon cancer, malignant melanoma and familial adenomatosis polyposis. In these instances of family with a strong history of cancer a comprehensive evaluation of personal and family history is obtained and this information is used to develop a personal pedigree identifying the genetic history and potential cancer risk.

The purpose of cancer screening is to detect cancer before it is clinically apparent, early in its natural history before it has become systemic and spreads internally.

34

Cancer screenings that are provided by FHNP at their fixed site include screening mammography, clinical breast examination, total body skin examination, osteoporosis screening, prostate screening by digital rectal exam and prostate specific antigen testing (PSA) (blood test), lowdose spiral CT scan screening for lung cancer and colorectal screening.

An effort will be made to provide these services to the community, major corporations throughout the county and the Pinellas County School Board. Currently cancer screenings are being performed on site, at industry centers or at the FHNP Screening Center which is located at the FHNP Physician Group Surgical Institute. All screening

Operation Sunshine: The Sun Safety Program for the Pinellas/Tarpon Springs Community, named Operation Sunshine, was initiated in 2012 with the support of the Helen Ellis Memorial Foundation.

Through this effort, a mobile skin cancer screening program focuses on sun-safety education and on-site skin cancer examinations for the schools and industry in Pinellas County, as well as other community organizations. To date, Operation Sunshine has participated in three major community and industry health and wellness fairs, including fairs at Pinellas County Schools, Duke Energy, Tech Data and various assisted living facilities. Currently the program has led more than 25 on-site skin cancer screenings, providing more than 1,400 community members with free skin cancer screenings. Already, 62 screening events have been scheduled for 2014.

This year a sophisticated research database was designed and implemented, providing a statistical reporting mechanism that will allow us to better understand the needs of our community. This information is also shared with the screened patients and their health care providers for continuity of care. The cancer screening database also allows us to share important statistical data with our community partners.

Date Industry Location # Screenings 2/13/13 Tarpon Springs Golf Course Tarpon Springs, FL 18 3/5/13 Total Fitness Tarpon Springs, FL 30 3/6/13 Sun Toyota New Port Richey, FL 36 4/17/13 The Villages Healthy 100 The Villages, FL 52 4/24/13 Coral Oaks Assisted Living Palm Harbor, FL 22 5/3/13 Florida Hospital Tampa, Melanoma Friday for Employees Tampa, FL 57 5/6/13 Florida Hospital North Pinellas, Melanoma Monday Tarpon Springs, FL 64 5/20/13 and 5/23/13 Suite T office Random skin Screenings Tarpon Springs, FL 3 6/13/13 Pinellas County School Head Plant Operators Safety Harbor, FL 30 6/14/13 Military Entrance Processing Station Tampa, FL 6 6/26/13 Innisbrook Employee Health fair Palm Harbor, FL 9 7/25/13 Pinellas county School – food Services Clearwater, FL 38 8/7/13 Duke Energy Clearwater, FL 29 8/14/13 Pinellas County School – Admin and PE teachers Clearwater, FL 42 8/21/13 Villages Lecture And Screening The Villages, FL 64 9/5/13 St. Petersburg Community College Tarpon Springs , FL 10 9/17/13 FHNP Dr. Reintgen Lecture and Screening Tarpon Springs, FL 32 9/18/13 St. Petersburg Community College Clearwater, FL 18 9/25/13 Duke Energy – NPR New Port Richey 28 10/4/13 Tech Data Clearwater 218 10/11/13 Freedom Inn Assisted Living Tarpon Springs 7 10/17/13 PCSB Leland Bus compound St. Petersburg 12 10/17/13 PCSB – PTEC St. Petersburg 23 10/18/13 PCSB – Bear Creek Elem. St. Petersburg 11 10/18/13 PCSB – Pasadena St. Petersburg 13 10/24/13 PCSB – Bernice Johnson Clearwater 15 10/31/13 PCSB – Walter Pownall Transportation Largo 28 10/31/13 PCSB Walter Pownall Food Service Largo 19 11/7/13 PCSB – Curlew Creek Elementary Palm Harbor 27 11/7/13 PCSB – Lake St. George Elementary Palm Harbor 27 11/8/13 PCSB – Madeira Beach Middle Fundamental Madeira Beach 25 11/8/13 PCSB – Orange Grove Elementary Seminole 11 11/13/13 PCSB – Tarpon Springs High School Tarpon Springs 29 11/20/13 PCSB – Oak Grove Middle School Clearwater 24 11/21/13 PCSB – Coachman Site Clearwater 15 12/5/13 PCSB – Shore Acres Elem St. Petersburg 21 12/5/13 PCSB – Northshore Elem St Petersburg 18 12/6/13 PCSB – Highland Lakes Palm Harbor 23 12/6/13 PCSB – Tarpon Springs Middle Tarpon Springs 20 12/13/13 PCSB – Administrative Bldg Largo 24 12/13/13 PCSB – Osceola Fundamental 14 12/18/13 PCSB – Walter Pownall Maintenance 23 12/20/13 Tarpon Springs Fundamental Tarpon Springs 13

Total Screenings 1,248

35

As we continue to move forward in our endeavors with Operation Sunshine, we are proud to share our accomplishments and the support of many companies who have joined our efforts of education and putting their employees’ health first. These corporations include Pinellas County Schools, Duke Energy, Tech Data, and various assisted living facilities.

This ground breaking program at FHNP continues to proudly recognize Sun Toyota who generously donated a 2012 Toyota Tundra which has been traveling throughout the county to schools and companies performing on-site education and skin cancer screenings. It is the goal of FHNP to expand the screening program to include cancer screenings for lung, breast, colon, cervical and prostate cancers.

The FHNP Cancer Screening Program continuously promotes health and awareness and actively participates in community activities that encourage consumer wellness for the reason that finding cancer early offers greater hope for a cure.

Rosemary Giuliano, ARNP, MSN Christine Sparks, AS Director, Oncology Program Cancer Screening Program Coordinator Florida Hospital North Pinellas Florida Hospital North Pinellas Clinical Instructor USF School of Nursing

36

Community Outreach At Florida Hospital North Pinellas we are committed to extending the healing ministry of Christ to those we serve through our care, compassion and expertise. Offering state-of-the-art care as a benefit to our community means not only providing the latest in testing and treatment, but also focusing on prevention and education. Just the same way that hundreds of thousands have trusted Florida Hospital North Pinellas for their care we believe in creating a sacred trust to not only provide healing when you are sick but to provide education and screening to keep you well.

As an organization, we have developed a community health assessment that looks closely at our local community and identifies its main health needs and concerns. These needs drive the screening, education, outreach, sponsorship, and support that our organization seeks to provide. During the past year we have seen an explosion in the number of people attending “Healthy Happenings� events which represents a 200% increase over last year alone. Year to date we have touched the lives of more than 12,283 people, hosted more than 216 screenings and lectures, and connected greater than 5,689 people with lifesaving care as a result. These events are minimal to no cost to the participants and are aimed at reaching out and enriching the lives of our community. To find out more about our wide variety of Healthy Happenings events, please visit FHNorthPinellas.com or call (727) 943-3600.

We look forward to seeing you at a Healthy Happenings event, as we work together to enrich the health and wellness of our community.

Paul S. Hoover Jr. Vice-President, Business Development Florida Hospital North Pinellas

Christine Longley, MS, BS Manager, Community Outreach and Volunteer Services Florida Hospital North Pinellas

37

Presentations 2/13/13

Understanding the Importance of Cancer Screenings – Dr. Douglas Reintgen The Center of Health, The Villages, FL

2/20/13 Restore Breast Beauty! – Dr. Effie Pappas Politis FHNP, Tarpon Springs, FL 3/27/13

A Test for Your Breast - Dr. Douglas Reintgen The Center of Health, The Villages, FL

3/28/13

Ask the Experts – Moderator: Dr. Michael B. Longley, Dr. Norman S. Abbott, Dr. Paul M. Arnold Dr. Louis I. Astra, Dr. David S. Fine, Dr. Rajneesh Mathur, Dr. Edward A. Norman, Dr. Cynthia P. Roever Innisbrook Golf Resort & Spa, Palm Harbor, FL

4/26/13 Ask the Pharmacists FHNP, Tarpon Springs, FL 5/23/13

Colorectal Potpourri – Dr. Lourdes Santiago St. Petersburg College, Tarpon Springs, FL

6/13/13

Women’s Health – When to Start Health Screenings – Dr. David Marler Leo’s Restaurant, Palm Harbor FL

7/31/13

Modern-day Melanoma – Dr. Douglas Reintgen The Center of Health, The Villages, FL

8/21/13

Living a Healthy Life – Why Taking Control of Your Health Matters – Dr. Douglas Reintgen The Center of Health, The Villages, FL

9/11/13

Melanoma Overview – Dr. Douglas Reintgen The Center of Health, The Villages, FL

9/13/13 In-service on Implantable Ports – Dr. Louis Astra FHNP, Tarpon Springs, FL

38

9/17/13

Fun in the Sun – Dr. Douglas Reintgen The Center of Health, The Villages, FL

9/26/13

Thoracic and Vascular Surgery All You Need to Know – Dr. Louis Astra Massimo’s, Palm Harbor, FL

11/6/13

Melanoma Overview – Dr. Douglas Reintgen The Center of Health, The Villages, FL

11/20/13

Golf Talk – Dr. Douglas Reintgen Cypress Run Golf and Country Club, Tarpon Springs, FL

CME Lectures 2/13/13

The Evolution of Sentinel Lymph Node Biopsy in Melanoma and Breast Cancer Patients and its Applicability in 2013 – The Villages, FL • Dr Douglas Reintgen presenter

Interviews Publications: • Healthy Happenings Magazine; Summer 2013 • Healthy Happenings Magazine; Fall 2013 • Healthy Cells Magazine; October 2013 • Tampa Tribune; September 2013 Radio: • Douglas Reintgen, MD, “Melanoma Risks”- 105.5 WDUV; May 2013 • David Marler, MD, “Gynecological Cancer” - 970 WFLA; September 2013 • David Marler, MD, “Gynecological Cancer” and Douglas Reintgen, MD, “Breast Cancer – Top 3 Advances in Treatment” 820 WWBA-AM, 1110 WTIS-AM,1250 WHNZ, 1470 WMCG-AM; October 2013

Community Supported Events • • • • • •

AllTrust Golf Tournament Beach to Bayou Sunset Beach Concert Series, Tarpon Springs Doctor Idol Tampa Bay, Rosemary Giuliano, Event Chair American Cancer Society, Tarpon Springs Relay for Life, Rosemary Giuliano, Event Chair American Cancer Society, Oldsmar Relay for Life, Kate Archer, Event Chair

Fundraisers • • • •

Dog Wash Tarpon Springs, April 2013 Pink Army October 2013 Cookbook sales Multiple Bake Sales

39

Oncology Research The impact of research in the fight against cancer over the last 30 years has arguably been the catalyst for the improvement in outcomes for the treatment of various types of cancer. Clinical excellence is derived from active research, and in turn, active research requires patient trust, clinician tenacity, and funding from the public and private sectors. The American Cancer Society (ACS) estimates that in 2013, 1.66 million new cancers will be diagnosed, and more than 570,000 souls will succumb to cancer this year. The Florida-specific statistics are estimated at over 118,000 and more than 42,000, respectively.

The overall five year survival rate has been steadily improving owing to the improvement in diagnosis, treatment, and prevention.

S y AC c, er F g , i r MD scop c Su , k i o ota apar riatr K .

L a P

B l, j Ra nera lic & Ge tabo Me

Active research requires patients who are willing to believe in the future of cancer research. The role of the patient is fundamentally important as the gatekeeper to disease. They bring the symptomatology, the clinical findings, and the pathology together in a way that allows the clinician to make sound decisions and recommendations in the patient’s best interest. The fiduciary role of the clinician is indelibly on display at this critical juncture of the patient’s journey. It can seem like an unending odyssey of appointments, tests and opinions when faced with a diagnosis of cancer.

Multidisciplinary committees, consensus conferences, and clinical trials all culminate in our ability to provide the best care based on the best evidence. That evidence is bore out of the faith that better information leads to improved care.

FHNP and its physicians and nurse practitioners are committed to being the leaders in cancer care and research in northern Pinellas County.

Survival rates after treatment for cancer have been increasing over the last several years. Much of this is attributed to improvements in screening and diagnostic programs working in synergy with aggressive Primary Care. Additionally, advanced treatment methods and existing research form the basis upon which the fabric of cancer care is based. This fabric, when interlaced with research and clinical trials, forms a quilt of comfort with trusted health care providers and clinicians that patients have come to trust and rely on at Florida Hospital North Pinellas (FHNP).

As of October 2009, the National Cancer Institute Physician Data Query (PDQ), which includes the world’s most comprehensive cancer clinical trials registry, includes abstracts of more than 8,000 clinical trials for cancer treatment, genetics, diagnosis, supportive care, screening, and prevention. The PDQ includes trials sponsored by the National Cancer Institute and also many clinical trials sponsored by pharmaceutical companies, medical centers, and other groups from around the world.

40

FHNP and its physicians and nurse practitioners are committed to being the leaders in cancer care and research in northern Pinellas County. We offer multiple specialists in several areas from gastroenterology to hematology to thoracic to skin and soft tissue oncology services. The wonderful working relationship between Primary Care Physicians, Gastroenterologists, Surgical Oncologists, Medical Oncologists, Radiation Oncologists, Pathologists, Diagnostic and Interventional Radiologists, Nurse Practitioners, and Clinical Trials staff allows the Florida Hospital North Pinellas Physicians Group to administer the

highest quality care that rivals nearby university institutions. But why be rivals when we can be partners? FHNP and the University of South Florida (USF) work together on cancer research and research initiatives, forging a relationship in the Tampa Bay area that allows our community hospital to provide our constituents with cutting edge academic treatment. Sir Isaac Newton once said “If I have seen further, it is by standing on the shoulders of giants.� These giants are our mentors, colleagues and predecessors. It is incumbent upon us to build on that which has been provided as the foundation of cancer care and research.

Best Regards, Raj P. Kotak, MD, FACS General, Laparoscopic, Metabolic & Bariatric Surgery Florida Hospital North Pinellas Physician Group

41

Genetic Counseling & Testing Florida Hospital North Pinellas (FHNP) offers genetic counseling and testing for a variety of cancers through our community medical oncologists as well as through the University of South Florida (USF).

Cancer Genetic Counseling is an important part of FHNP’s commitment to providing world-class oncology services. This program serves individuals who are at increased risk for hereditary cancer.

Patients and families with many different types of cancers, including breast, ovarian and colon cancer are seen.

P CC F CP, A F D, M , t igh r W y aw olog h S L. Onc l i Ga dical Me

Cancer Genetic Counseling is an excellent example of FHNP’s dedication to personalized medicine.

Through advanced techniques such as genomics, we are optimizing the health of each patient by calculating their risk of developing a cancer. If patients are identified at being at an increased risk, prophylactic surgery or medical treatment may be indicated to lessen their risk.

I am a board-certified medical oncologist with experience in genetic counseling and testing. I trained at the National Cancer Institute in Bethesda, Maryland, with the Family Studies Section of the Cancer Epidemiology program. I subsequently initiated and directed the Cancer Genetics Screening program at the Lifetime Cancer Screening Center at Moffitt Cancer Center in Tampa, Florida.

While practicing in the New Port Richey community, I continue to offer cancer genetics counseling and testing to my patients at Florida Cancer Specialists and Research Institute; and work closely with the medical staff and oncology program members at Florida Hospital North Pinellas.

Sincerely, Gail L. Shaw Wright, MD, FACP, FCCP Medical Oncology Florida Cancer Specialist & Research Institute

42

Integrative Oncology Integrative oncology makes use of complementary medicine in addition to conventional medicine in a deliberate, personalized and safe manner to optimize health, quality of life and clinical outcomes.

Complementary therapies, used in addition to mainstream care, are supportive measures that help control symptoms, enhance well-being and overall patient care. Over time, many complementary therapies have been proven safe and effective. These are now integrated into mainstream care, producing integrative oncology, a combination of the best of mainstream cancer care and rational, data- based complementary therapies.

Complementary therapies are applied not to treat cancer or any other malignancy but rather to treat the symptoms associated with cancer and its routine treatments. The services can be broken down into three main categories : biological based therapies that include personalized diet modifications; mind body practices including relaxation techniques and movement based therapies like yoga and tai-chi and lastly, manipulative and body based techniques such as massage and acupuncture.

Nu Me rudd di in ca

l O Joo nc ma, ol og MD y

Mind body therapies reduce anxiety, depression and mood disturbance in cancer patients, and assist with coping skills. Mind-body techniques may also help reduce chronic low back pain, joint pain, headache, and procedural pain. For example, massage therapy is now considered as part of a multimodality treatment approach in lung cancer patients who experience anxiety or pain.

Acupuncture is also strongly recommended as a complementary therapy for pain control when pain is poorly controlled, or when side effects from other modalities are clinically significant. For example, nausea and vomiting, common side effects associated with chemotherapy can be effectively controlled with acupuncture.

Similarly, under guidance of a trained dietician, nutritional strategies to reduce the risk of cancer as well as diet and lifestyle strategies to maximize wellness once cancer therapy is completed are part of integrative oncology services.

Sincerely, Nuruddin Jooma, MD Medical Oncology Florida Cancer Specialists & Research Institute

43

Multidisciplinary Cancer Conference Cancer conferences (Tumor Board) are a major, monthly educational element in the Florida Hospital North Pinellas (FHNP) Oncology Program. They are the clinical mirror of the Committee on Cancer meetings. The Cancer conferences are a requirement for accreditation by the American College of Surgeons (ACoS).

The Cancer Conferences are held monthly for discussion of the most appropriate management of specific cancer patients. The conference consists of a multidisciplinary team of physicians and ancillary staff members whose primary goal is to educate and improve cancer care at FHNP. Primary care and other community physicians attend. Staff from outside FHNP brings new knowledge into the organization.

The conference provides prospective and retrospective cancer case reviews. This ensures patient access to consultative services that include pretreatment evaluation, tumor staging, treatment strategies, referrals to clinical research protocols and post treatment rehabilitation. The treatment strategies are enhanced by adopting NCCN Clinical Practice Guidelines in Oncology so as to reflect national standards. In 2012 FHNP submitted 384 new primary and historical cancer cases showing an increased volume of 166%, 66% more than expected growth.

44

Since this committee discusses specific patients and the ultimate treatment decisions still rest with the managing physician who evaluates the various treatment options, the most appropriate care for the patient can be determined.

This educational conference is designated by Florida Hospital Tampa for CME Credit 1 category for the staff attending. But also from this committee comes educational topics the FHNP CME/Educational department can use in educating the community medical and hospital staff in current oncology concepts.

Sincerely, Jeffrey Smith, MD, FCAP Pathology Florida Hospital North Pinellas

Imaging Department Light in the Time of War Diagnostic Imaging, previously known as Radiology, is about the realm of light. Without light there is darkness. If one were to walk into dark unknown room a path through that room can not be readily made.

Turn on the light and direction can now be made.

Diagnostic Imaging helps provide that direction and is often described by the light as shades of gray or sometimes color. Light that is used to obtain the images and then the light to view the images by the diagnostic imager. The diagnostic imager can help guide the physician and patient through that room.

Interventional Radiology helps provide support by diagnosing disease such as cancer through image guided biopsy techniques.

Da Ra vid V dio ar lo gas gy ,M D

Paralleling the understanding of light was the advent of computers and technology. High speed powerful computers. With modalities such as Computerized Tomography or Magnetic Resonance Imaging, we can peek into the patient’s anatomy with little disturbance.

But with all of this technology comes the human caring face of the department of Diagnostic Imaging.

People who care about you, the patient. Technologists, nurses and physicians; all there to help guide the patient down this lit path.

In our war against cancer, Diagnostic Imaging has been and will continue to be there. To help provide the light... to win the many battles that we all face.

Sincerely, David Vargas, MD Radiology Florida Hospital North Pinellas 

45

Pathology & Laboratory Medicine The Florida Hospital North Pinellas Department of Pathology and Laboratory Medicine is a College of American Pathologists-accredited laboratory. By virtue of key partnerships with Florida Hospital Laboratories (Orlando, FL), Integrated Oncology (Irvine, CA), University of South Florida College of Medicine (Tampa, FL), and Agendia (Irvine, CA), the Department is able to provide comprehensive support for all phases of diagnosis and management of cancer patients.

The Pathology Department consists of two experienced board-certified pathologists plus key support staff, including histotechnologists, pathology assistants and office staff. Our main Clinical Laboratory is a CLIA-certified moderate complexity laboratory having a full complement of medical technologists, medical technicians, laboratory assistants, and certified phlebotomists.

The Pathology Department team is responsible for confirming prior outside microscopic diagnoses, assisting the surgeons with intraoperative consultations utilizing cytologic and frozen section diagnoses, and making accurate final microscopic diagnoses, which include pathological grading and staging of all cancers that are presented here. Over 90% of the cancers are diagnosed here only after intra-departmental review and consensus. The department relies on immunohistochemistry and other molecular diagnostic techniques (ie, EGFR mutation analysis by PCR, ALK by FISH, and BRAF gene mutation, etc.) to assist in determining the type of cancer cells involved, their prognosis, and selection of tumor-specific therapies. At present the prevailing weight of the tumor diagnoses made by the Department of Pathology consists of cutaneous, breast, urological, and thoracic neoplasms. Other integral services provided by the department include bone marrow biopsy interpretation including flow cytometry with cytogenetic analysis, and fine needle aspiration biopsy interpretation of both palpable and deep-seated tumors.

46

The pathologists assist clinicians, surgeons, and interventional radiologists during the specimen procurement phase of cancer care to assure specimen adequacy and quality. The pathologists are continuing to collaborate in the MINT study, which is a nation-wide clinical trial evaluating the role of gene expression profiles in the treatment of women with advanced breast cancers. New departmental initiatives that will enhance the quality of cancer care include: standardization of pathological report addenda with a molecular testing result summary and instructions to find within the HIS (Cerner) where the full report can be found; creation of a synoptic report format for breast needle biopsy specimens to accommodate benign and neoplastic pathology; an intradepartmental review process to determine if the tumor synoptic forms

are up-to-date in terms of content; adoption of an algorithmic approach for molecular testing on all pulmonary adenocarcinomas; and, creation of a standardized process for lymph node harvesting in all neoplastic colectomy specimens.

During the diagnostic phase of cancer care, the pathologists collaborate with medical oncologists, radiation therapists, and oncologic surgeons to provide the information needed to optimize and even individualize patient therapy. This latter responsibility is further promoted by active participation in the hospital’s monthly tumor board where educational and challenging oncologic cases are presented for consensus regarding treatment. Further, the pathologists are instrumental in advancing public awareness and knowledge of common tumors by participating in local community health fairs.

During the management phase for cancer patients the Clinical Laboratory provides a comprehensive menu of key tests to assess patient status and ensure their safety. Monitoring for toxicity of certain chemotherapies, assessing bone marrow response to therapy, and following tumor markers are some of the frequently used tests in this setting. The FHNP cancer program has made great strides in the care it provides to our community. The Department of Pathology and Laboratory Medicine looks forward to participating in the care of these challenging patients.

Respectfully Submitted, Stephen F. Morris MD, FCAP Pathologist Florida Hospital North Pinellas Department of Pathology and Laboratory Medicine Laboratory Medical Director/ Laboratory Services Director

47

Clinical Studies Two clinical studies were performed at Florida Hospital North Pinellas to improve patient care and outcomes. They are described below.

Clinical Study - Pharmacy Department Report on reduction of time for chemotherapy admixture for the Hyperthermic Isolated Isolated Limb procedure.

.Ph tor R a , il a ordin v A ry al Co a G inic Cl

The reconstitution and preparation of Melphalan for use in limb perfusion therapy involves a complex set of variables. These must be taken into consideration in the effort to provide a product that retains its potency, while still being available at the earliest moment necessary. The balance in timing requires cooperation between the surgical staff and the Pharmacy Department. When we began the isolated limb perfusion surgery here, the communication between pharmacy and the surgical team was somewhat ineffective and imprecise, leading to delays in the preparation of the product, waste of product, waste of surgical team time, and unnecessary constraints placed on the ability of the Pharmacy to perform its other hospital wide duties. Several changes would be required to streamline the entire process.

It was determined by the Pharmacy that the MINIMUM amount of time to prepare the product was 30 minutes, +/- 5 minutes, depending upon individual dose and dissolution time for various lots of drug. The time between reconstitution/dilution and administration of Melphalan should be kept to a minimum because of the inherent instability of the drug. Over as short a time as 30 minutes, a citrate derivative of Melphalan has been detected in reconstituted material from the reaction of the drug with Sterile Diluent. Upon further dilution with saline, nearly 1% label strength of Melphalan hydrolyzes every 10 minutes. A brief literature search, including the manufacturer’s package insert recommendations, showed differing acceptable time limits after reconstitution. The Pharmacy concluded that a 45 minute time frame, from notification that the patient was being brought into the procedure room (thus initiating the admixture chain of events), until the hand off to the Surgical team, would allow for preparation and delivery, while avoiding product degradation and delay of the surgical process.

In one early instance, the Pharmacy had not been notified that a patient had been booked. This prevented the changes in staffing duties and times necessary to insure a Pharmacist would be in position to immediately act upon notification from the surgical team. Also, it can take up to an hour to sterilize the hood, change the glove-box gloves and set up for the reconstitution and labeling process, so any unforeseen cases would automatically require this additional time. Also early on, the calls for the initiation of the admixture process were not ideally timed with the needs of the perfusionist, resulting in unnecessary delays in the surgical process.

48

As previously stated, through a mutual collaboration, several improvements were made to the process, with significantly beneficial outcomes.

These changes were as follows: • The Surgical team notified the Pharmacy immediately upon booking a patient for Melphalan perfusion with specific date, time and patient information, allowing for set-up of the chemo hood, and staffing adjustments. • The Surgical team, on the day of surgery, has called the Pharmacy at the time the patient is being wheeled into the procedure room. (Time zero for the Pharmacy) At that moment, the pharmacist previously selected initiates the process. • The time from time zero until the product is placed in the hands of surgical team was lengthened to 45 minutes. (Note that the time from actual reconstitution of drug to delivery was less than the 45 minutes.)

As mentioned earlier in this report, there is little that can be done to change the minimum time it takes to actually prepare the drug itself. Our efforts have been to negate the possible degradation of the admixture while preventing any waste of surgeon or perfusionist time. Given the stability profile of the drug and the relatively invariable handling time, from a Pharmacy perspective, the changes put in place have made for a much smoother process. It has allowed us to have all the pieces in place, ready to go at the moment we receive the call, with no delays in the department or delays in our service to the rest of the Hospital.

As for future improvements, we would suggest limiting calls to the pharmacy after the initial call (time zero). A second call would only be necessary should the drug not be delivered to the surgical team in the specified 45 minute window. Repeated calls to the pharmacy can only delay the process and interrupt service for the rest of the hospital.

The feedback we have received after implementation has indicated that changes have had an appreciably significant impact. As we are not present in the room, we must allow the surgical team to better describe the outcomes.

Respectfully submitted, Gary Avila, R.Ph Clinical Coordinator Florida Hospital North Pinellas Pharmacy Department

49

Clinical Study - Nutritional Services Nutritional Consult for Identified Cancer Patients (Patient- Centered Care) Objective: To obtain baseline data for nutrition consult and intervention (patient-centered outcomes) relating to all cancer patients.

D/N L , r RD nage , d a iel n M f f e tio Sh utri i N bb Bo inical Cl

Methods: Data was extracted from patient charts in Cerner at Florida Hospital North Pinellas (FHNP) whom had any (new or previous) diagnosis of cancer. Dietitians reviewed patient charts in which they were consulted and if the patient had a past medical history of cancer or a new diagnosis of cancer, the patient was included in this study. Dietitians could be consulted by nurse/physicians for new diagnosis of cancer. Dietitians included if they made a nutrition intervention to the cancer patients. Nutrition interventions include food preferences/ tolerance, tube feeding and total parental nutrition (TPN). The data extracted from Cerner was compared to the Dietitians’ data monthly. This is a retrospective review of all patients with any cancer diagnosis at FHNP between February 2013 through October 2013.

Results:

February 2013 through October 2013: 605 inpatients at FHNP had a diagnosis of cancer The dietitians provided nutrition intervention in 366 (60%) patients .

Table 1: Total Number of Patients with a Diagnosis or Past Medical History of Cancer and Number of Patients Dietitians Assessed with a Diagnosis or Past Medical History of Cancer with Nutrition Intervention

FEB-13 MAR-13 APR-13 MAY-13 JUN-13 JUL-13 AUG-13 SEP-13 OCT-13

50

Total # Pts d/c with Cancer Dx. (IP / OBS)

Diagnosed History of Cancer

Newly Diagnosed Cancer Patients - ID

By Nutrition

70 68 59 74 69 82 55 69 59

1 11 8 23 20 38 18 48 33

1 0 1 2 4 2 1 1 6

Nutrition Consults Intervention

2 11 9 25 24 40 19 49 39

2 11 9 25 24 40 19 49 39

% Consult to total diagnosis

2.86% 16.18% 15.25% 33.78% 34.78% 48.78% 34.55% 71.01% 66.10%

Dietitians have an important role in the cancer patients’ plan of care with the health care team members. Nutrition intervention is a vital role in the survival of cancer patients. Depending on the type and location of cancer, nutrition support may have to be utilized for the patient’s survival during the cancer treatment. Patients may not be able to tolerate regular food and may need a modified diet and modified food preferences as well. The calorie and protein needs of patients undergoing cancer treatment are also much higher than the average hospital patient because of their hypermetabolic state. Dietitians are integrated with the health care team to help assess and intervene these patients with their knowledge of nutrition and nutrition support.

This study shows that the dietitians only assessed and intervened on 60% of the cancer patients that had a new diagnosis of cancer or past medical history of cancer. To increase the number of assessments and interventions of patients with a new diagnosis of cancer, the dietitians will work and communicate with case management, nursing and physicians so they are consulted to see the patients. In the future, the dietitians’ goal is to assess and intervene on 100% of new diagnosis of cancer patients and to increase the total percent of consults for patients with a past medical history of cancer.

Conclusion: The results of this study show that the dietitian did not receive a consult for 40% of patients with a diagnosis or past medical history of cancer. Dietitians are an important role in the cancer patient’s plan of care to assess the patient’s nutrition needs and give recommends for nutrition support, preferences or supplements. To improve the number of consults ordered for the dietitians the Clinical Nutrition Manager will meet with the Director of Case Management and RN Cancer Lead.

Sincerely, Bobbi Sheffield, RD, LD/N Clinical Nutrition Manager Morrison Healthcare Florida Hospital North Pinellas

51

Care Navigation

n

np

Ms , C -

r ,A n re nd st o i F A. pital e s in er l Ho h t K a rgica Su

Care navigation for the cancer patient is a role that has been incorporated into the multidisciplinary patient care at Florida Hospital North Pinellas. The care navigation role has been initiated for the advanced registered nurse practitioner (ARNP) that works closely in conjunction with the primary care physician, as well as the oncology specialist and surgeons. The ARNPs goal as the navigator of patient care is to assist patients in circumnavigating among the complex health system. The care navigator ensures patient access to cancer care services in order to provide quality care throughout their caner continuum.

The ARNP becomes an integral part of the overall patient’s care by being the patient advocate, educator, and emotional supporter. The support provided by the ARNP will improve quality of life, decrease psychological distress, improve functional status, and increase patient satisfaction with the comprehensive care provided.

The ARNP is instrumental in educating the complexities of cancer and creating individualized treatment plans that provide access to resources such as physical and occupational therapies. In addition to providing direct patient care, the ARNP also coordinates the scheduling of diagnostic examinations and surgical interventions if needed for the oncology patient. The ARNP functions as the central point of contact for the patient, their family, as well as the medical providers to facilitate collaboration, communication, and coordination of care. The ARNP serves as the liaison for the patient to ensure seamless, individualized patient care from the moment of diagnosis through the culmination of cancer treatments.

ARNPs serve as an advocate to recognize cost saving improvements in the oncology patient services, as well as keeping abreast of the latest evidence-based literature to facilitate the cancer specialists and primary care physicians. The ARNP also helps reduce inappropriate emergency room visits, as well as hospital admissions for the oncology patient that could predispose the patient for increase risks and complications. They can ensure the continuity of efficient and effective care delivery with vigilant symptom management, and prevent unnecessary test duplication that would drive up health care costs.

Care Navigation and patient-centered oncology care is an emphasis in the quality standards issued by the Commission on Cancer (CoC) of the American College of Surgeons.

Sincerely yours, Katherine A. Fondren, ARNP-C, MSN Surgical Hospitalist Surgical First Assist Florida Hospital North Pinellas

52

Oncology Nursing 2013 has been an exciting year for nursing education at Florida Hospital North Pinellas. The hospital’s nursing team, through various opportunities, has significantly enhanced their knowledge and skill level. Through every activity, the nursing team is helping to grow the hospital into a premier place to have treatment for various forms of cancer. Our nurses realize that learning is ever-changing, and is a personal commitment by each of us to ensure the highest level of care is provided to our patients.

Some major milestones in nursing education met in 2013 include: 13 nurses in June 2013 became officially certified in the management and administration of chemotherapy drugs (Donna Stoehr, Cindy Bear, Barbara Buscemi, Elizabeth Celeste, Michelle Ramnath, Stephen Iulg, Sandra Drake, Pamela Delgrosso, Denise Lewis, Richard Chard, Laura Burke, Buck Hunt, and Alison Dolzonek); Dr. Astra conducted an implantable port inservice in September 2013 where over 30 hospital nursing attendees became well educated on the usage and management of the main device that is used for chemotherapy infusions; Daryl Sample (PICC Team Supervisor) and Donna Stoehr (Oncology Nurse) conducted a hands on training and skills session on implantable ports in September 2013 where over 40 hospital nurses got to learn and demonstrate proper implantable port access, de-acces, and care; and, Donna Stoehr as the hospital’s Cancer Champion continues to provide monthly quality chemotherapy education to hospital nursing staff to ensure ongoing competency levels (chemotherapy drugs covered so far include: Cisplatine, Taxol, Rituximab, Doxorubicin and Etoposide).

In nursing education here at Florida Hospital North Pinellas we realize that the best care for our patients comes from professional growth of the professional health care provider. Some goals already set for the year 2014 include: (1) Continuing the monthly education and competency testing on various chemotherapy drugs led by Donna Stoehr the nursing cancer champion (2) Plan for another officially certified chemotherapy class in June 2014 for hospital nursing staff (3) Continuing to build the bridge between education and hands on practical experience with the implantable

port led by the PICC team supervisor Daryl Sample (4) Develop and start to facilitate quarterly chemotherapy labs (5) Continue to educate the bedside nurses of all the resources available for cancer patients and encourage them to make referrals to case management and Donna Stoehr so that more resources and options are utilized for each patient. Through strong dedication to their profession, the nursing team at Florida Hospital North Pinellas will continue learning and growing through various activities in 2014 to meet the hospital’s mission of “Extending the healing ministry of Christ” by providing respectful, evidenced based cancer care to those patients in need.

American Cancer Society referrals pathways for numerous months it has been a pleasure to educate the staff at FHNP on how to process referrals for our newly diagnosed cancer patients. In addition, it also has been not only crucial but beneficial to those patients who have had a recurrence of cancer. We are doing this by using a multidisciplinary approach. For example, combing nursing, case management, the outpatient clinic and the infusion center enables the processing of the American Cancer Society referrals easier and much more efficient. The ACS pathways are a positive and advantageous service to our cancer patients. It facilitates patients to receive a multitude of facilitation services such as wigs and breast prosthesis. The ACS also provides lodging, transportation, support groups, caregiver programs and cancer education classes. Recently, I have personally been educating the staff as to the process of nutritional consults by utilizing nursing processes with our ACS referrals, this has been an imperative addition to educating staff on the many resources readily available through the ACS referrals. The ACS is an utmost valued service for our patients at FHNP, and we embrace this resource.

Yours truly, Thomas Mazzant, MSN, RN, CPN Clinical Education Specialist Florida Hospital North Pinellas

Donna Stoehr, RN, CRRN Oncology Nurse Florida Hospital North Pinellas

53

Patient Experience Specialist I am proud to serve as our Florida Hospital North Pinellas Patient Experience Coordinator, and fill a unique role as a dedicated advocate for the experience of all patients and their families while in our care.

I work closely with patients as a care liaison and help to ensure that all ethical, operational and care standards are upheld, and all needs and concerns are addressed.

tor a n i rd o o r C cke nce u R ie lle xper e i E n Da tient Pa

We strive to anticipate the personal needs and monitor our patients’ well-being on an hourly basis so that our patients, family members and visitors can focus on the recovery of the patient. At Florida Hospital North Pinellas our team is dedicated to ensuring the very best in patient care and to providing an exceptional experience for all of our patients and guests. In fact, we have improved more than 350 percentile points in patient satisfaction since 2012. Additionally, we have been recognized this year by the entire Adventist Health System for our patient satisfaction scores, including as award recipients for excellence in patient experience for our Outpatient Surgery, Ambulatory Surgery and Emergency Departments.

As a faith-based organization, our mission focuses on extending the healing ministry of Christ.

True healing involves the mind, body and spirit, and as a community of care we seek to provide an environment dedicated to compassion and support. We continue to focus on doing our best for our patients in all aspects of their care, and our team works very hard to ensure each hourly round is purposeful and meaningful to make sure all patients are safe and well cared for. Each nurse and CNA has been trained on effective and purposeful hourly rounding.

Another initiative that we have implemented to ensure the very best in patient experience is hourly Nurse Leader rounds. Their rounds help to make sure that all patients are receiving the very best care possible.

Also, each patient receives a satisfaction survey on their return home. We hope that our patients take the time to share their thoughts with us and fill out the survey. We use their feedback to recognize our staff and to improve our patient experience. The feedback of our patients inspired our recent installation of a new nurse call bell system, flat-screen televisions, and improved cable services.

As our key advocate for patient experience, I serve as a link between patient care and our Florida Hospital North Pinellas leadership team. I research all opportunities that may arise for improvement in patient experience, and oversee the changes needed to answer these opportunities. For myself and the entire Florida Hospital North Pinellas family, our goal is to continue to exceed expectations in patient care, just as we would for our own families and people whom we love the most.

Sincerely, Danielle Rucker Patient Experience Coordinator Florida Hospital North Pinellas

54

Palliative Care The US Department of Health and Human Services Centers for Medicare and Medicaid defines palliative care as, “Patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”

National Quality Forum. A National Framework and Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report; December 2006. Available at: www.qualityforum.org/WorkArea/linkit. aspx?LinkIdentifier=id&ItemID=22041. Accessed September 6, 2012

St a Vic cy F Su e Pr Orl e o nc oa side ff E Federal Register. Medicare and Medicaid Programs: Hospice conditions of participation; final rule. June 5, st n d 2008; (73)109:32204.

Ho t Pa D, L lli sp ice ati CSW, ve Palliative care is beneficial for individuals and their families who are experiencing pain or other symptoms related to their Ca ACH P-S re cancer treatment. The hospitalized patient or family member may ask their oncologist for a referral to the in-patient palliative care W team. Out-patients may access support groups offered on the hospital campus as well as different locations throughout the community.

Florida Hospital North Pinellas is a strong proponent of palliative care. The hospital is working in partnership with Suncoast Hospice to ensure that all cancer patients and their families have access to palliative care while in the hospital, being treated in the clinic, or living their lives at home (Pinellas County). Palliative care is provided through an interdisciplinary team, including physicians, chaplains, and social workers.

Suncoast Hospice has provided a palliative care physician who makes rounds within the hospital. Consult requests can be made directly through the electronic medical record. Staff education continues to ensure all staff are aware of the benefits of palliative care. Additionally the hospital and Suncoast Hospice are working collaboratively to ensure discharged patients have access to additional palliative care services through Suncoast Hospice’s palliative home health program.

Goals of palliative care include continuing to expand physician consults, home palliative care services, and psychosocial services in different community locations, including the oncology clinic.

Goals continued: • Care is offered throughout the disease trajectory, beginning at the time of diagnosis • Palliative care is offered by an interdisciplinary team and available in the hospital as well as the community • Patients and families are partners in care. They, along with the palliative care team, and other healthcare providers collaborate and

communicate about care needs.

• The plan of care is based on the best available evidence • Palliative care is strength based and reflective of the patient/family’s culture, religious, and spiritual beliefs • Ethical and legal concerns are addressed through the palliative care team and the hospital’s ethics committee as needed • Palliative care is offered concurrently with curative care. The palliative care team may assist in the transition to hospice care when

the goals of care change.

• Patient and family desire for dignity and serenity during care, through the dying process and after death is maintained Sincerely, Stacy F Orloff EdD, LCSW, ACHP-SW Vice President Palliative Care, Suncoast Hospice

55

Wound Care & Hyperbaric Medicine Role of Hyperbaric Oxygen Therapy in Oncology and Radiation Induced Tissue Damage.

Hyperbaric oxygen therapy (HBOT) involves breathing pure oxygen while in a sealed chamber that has been pressurized at a pressure higher than sea level. Oxygen must be received by inhalation to be classified as Hyperbaric Therapy.š

S, AC F , .S. B .

M l B M. M-UH dica , e D P , M , AB ief M aling l e e t h Pa CWS d C ve H i v C n i Ra S, F nt a ovat FIC eside , Inn Pr ficer s Of stem y S

Oxygen, affects every system and cell of the body. Hyperbaric Chambers are either Monoplace meaning the treatment of one person at a time or Multiplace, meaning more than one individual can be treated at a time. At Florida Hospital North Pinellas, Monoplace Chambers are used.

HBOT is probably best known and recognized for the treatment of diving injuries. However, there is scientific evidence that supports the benefit of utilizing HBOT for the treatment of fourteen diagnoses. These diagnoses are recognized by the Undersea and Hyperbaric Medicine Society and the Center for Medicare, Medicaid Services. It is important to note that Oxygen is considered a drug by the FDA. Florida Hospital North Pinellas Wound Healing Institute treats a number of those fourteen diagnoses on a regular basis.

For those patients anticipating Radiation Treatment for oral cancer or if the radiated area will include the head and neck, a pre radiation oral evaluation by a dentist that treats oral cancer should be strongly encouraged as an overall part of the plan of care. Radiation Therapy’s goal is to destroy cancerous cells through oxygen deprivation.2 For the Radiation Therapy patient, a risk factor is the immediate or delayed response to oxygen deprivation at the cellular level. Because of oxygen deprivation, normal cellular tissue damage occurs and leads to vascular destruction and fibrosis. 3 Breathing oxygen at 100% under pressure, HBOT promotes angiogenesis and neo-vascular enhancement of oxygen deprived tissue.

It is now understood that ORN is due to avascular aseptic necrosis not infection. Dr. Robert Marx, D.D.S, established a now well respected and practiced protocol for those patients that fall into this category. 4 Post Radiation Therapy Patients of the head and neck anticipating oral surgery or tooth extraction should receive HBOT. Pre and post oral surgical intervention to prevent further bone destruction and enhance healing. Emphasis is placed on the importance of pre-surgical intervention. Hyperbaric Oxygen utilized for Mandibular Radiation Necrosis (ORN) is now accepted practice and a standard of care.

Radiation Therapy is also utilized for tumors in the pelvis region including rectal, prostate and gynecologic malignancies. Benefits of HBOT have been shown in cases of Radiation Cystitis, Radiation Proctitis and Enteritis. Hemorrhagic Cystitis can be life threatening. Early intervention significantly impacts outcomes in hemorrhagic cystitis; partial or complete resolution occurred in 96% of patients.5

56

In the past there has been a commonly held belief that Oxygen contributes to the growth of tumor and causes the spread of cancer. In fact, this is not the case. There has never been a Randomized Controlled Study to substantiate this hypothesis. Current trends in the literature, have a growing body of articles to support that the opposite is true and worthy of further investigation. Tumors thrive in a hypoxic environment, and must seek a new blood supply due to destruction and hypoxia in their current environment/ community.

Case Management Services offered at The Wound Healing Institute of Florida Hospital North Pinellas include Hyperbaric Oxygen Therapy, Wound Care Management, Compression and Edema Management, Negative Pressure Therapy, Bi-Layered Living Skin Substitutes, Nutritional Counseling and Assistance, Off-Loading and Pressure Relief and Patient and Caregiver Education.

The Physicians and Staff at the Wound Healing Institute look forward to the opportunity to work with the Oncology Team to provide State of the Science care to the patients that are served.

1. Gesell, LB, Chair and Editor.(2008) Hyperbaric Oxygen Therapy

Indications, 12th Edition. The Hyperbaric Oxygen Therapy

Committee Report. Durham, NC: Undersea and Hyperbaric

Medical Society.

2. http://oralcancerfoundation.org/ 3. Gesell, LB, Chair and Editor.(2008) Hyperbaric Oxygen Therapy

Indications, 12th Edition. The Hyperbaric Oxygen Therapy

Committee Report. Durham, NC: Undersea and Hyperbaric

Medical Society.

4. Gesell, LB, Chair and Editor.(2008) Hyperbaric Oxygen Therapy

Indications, 12th Edition. The Hyperbaric Oxygen Therapy

Committee Report. Durham, NC: Undersea and Hyperbaric

Medical Society 5. Corman JM, McClure D, Pritchett R, Kozlowski P, Hampson NB.

Treatment of radiation induced haemorrhagic cystitis BJU Int 2005;96:107-9 Respectfully Submitted, Ravi Patel, MD, M.B.B.S., FACS, FICS, FCCWS, ABPM-UHM President and Chief Medical Officer, Innovative Healing Systems Chief of Surgery – Florida Hospital Carrollwood, Tampa Medical Director of North Pinellas Wound Healing Institute

The Florida Hospital North Pinellas Case Management Department is staffed with on-site experienced Registered Nurse Case Managers, who work closely with patients, families, nurses, physicians, support services, postacute providers, and resource organizations. Thus, we ensure a safe discharge and smooth transition back into the community. Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes (Case Management Society of America, 2012).

Our Registered Nurse Case Managers meet with patients after admission and continue through the hospital stay as needed to assess for discharge planning and resource management needs.

The Registered Nurse Case Manager may be able to assist with arranging equipment, home health care services, out-patient services, medication assistance programs, hospice services, and palliative care consultations.

The Case Management Team collaborates with the American Cancer Society, maintains information on local resources, and provides information to our patients as needed. Patients, families, physicians, or nurses are welcome to ask for an evaluation by a case manager.

Sincerely, Kathryn Welch, MSN, RN, CCM Director, Case Management Florida Hospital North Pinellas

57

Supportive Services Rehabilitation Services Lymphedema Rehabilitation

Lymphedema is the swelling of the extremity as a result of lymph node removal or radiation therapy. It usually affects only one limb, but may also involve the face, trunk, abdomen, or genitals. Initial symptoms include aching or heaviness in the limb, feeling of fullness or tightness in the limb, decreased flexibility, or visible swelling.

The treatment plan for lymphedema is tailored to each individual case.

Presently, the most effective and least invasive approach is a two phase process: The first stage utilizes Complete Decongestive Therapy (CDT) and is provided by a licensed physical therapist. In the second phase the patient plays a larger role in his or her ongoing care self-care, as the patient is taught self-management skills. Amy Brenner, PT, DPT has received specialized training in lymphedema rehabilitation and administers the program, which is housed in the outpatient rehabilitation department on the first floor of the hospital.

Pulmonary Rehabilitation

The program’s main objective is to improve and maintain the function of the lungs. This is accomplished by providing exercise training and education, in order to improve the patient’s physical and psychological sense of well-being and quality of life. COPD, Emphysema, Lung Surgery, and Lung Cancer are all conditions that encourage pulmonary rehabilitation. The program is housed in the outpatient rehabilitation clinic at Florida Hospital North Pinellas. Dr. Amir Noorani is the medical director of the program, and it is administered by Linda Wonderly, RN, and Margaret Luedke, RT.

Physical Therapy

A body in motion tends to stay in motion and the physical therapy team at Florida Hospital North Pinellas is here to keep patients in motion.

Our team personalizes the treatment plan across the continuum of care with the goal of getting patients back to a healthy active lifestyle. All the therapists are committed to lifelong learning and are involved with the Florida Physical Therapy Association as advocates for patients and therapists.

58

Acute care services are provided seven days per week. Upon physician request a physical therapist will assess a patient’s current level of mobility and make recommendations to prevent the negative effects associated with bed rest, initiate movement post-surgery, and in consultation with the physician and nurse case managers, determine what level of care and equipment is required post discharge. Post-surgical patients are encouraged to begin mobilization early in the recovery process. The acute care team consists of two physical therapists, two physical therapist assistants, and one physical therapy aide. Collectively the team has over 75 years of experience in the field of physical therapy.

Outpatient physical therapy services are located on the first floor of the hospital just by the main entrance. Patients have dedicated parking spots and the department is open Monday through Friday. Treatment sessions are personalized and consist of a one-on-one session with the therapist.

Private treatment rooms are available and most major insurance plans are accepted. The front office team will verify a patient’s benefits in order to get them scheduled as quickly as possible. Patients are referred by their physician or they can access the department directly. The overall emphasis in conjunction with the patient’s goals is a rapid return to the patient’s optimal functional level. Services include but are not limited to postsurgical rehabilitation, cancer rehabilitation, lymphedema rehabilitation, and general strengthening and endurance training. The outpatient team consists of one physical therapist and two physical therapist assistants.

About 250 new patients are seen each year. Collectively the team has over 25 years of experience working at FHNP.

Occupational Therapy

Cancer and its treatment can cause interruptions in daily routines affecting how individuals perform their self-care, work, leisure, or social activities. While Physical Therapy addresses improving a patient’s overall strength, endurance and joint range of motion for mobility, Occupational Therapy addresses: Management of activities of daily living (ADLs) such as bathing, dressing, grooming, feeding and toileting through adaptations/modifications to the activity and environment, and/or the use of assistive devices/technology to make the task easier and safer to perform independently. Management

of instrumental activities of daily living (IADLs) such as meal preparation, housework, shopping and transportation are similarly addressed to allow individuals to remain independent in the community both during and after cancer treatment.

If any type of oral (lips, tongue, palate, mandible, etc.) resection is needed, then a patient’s speech intelligibility may be impacted. The patient would benefit from speech treatment to learn exercises and compensatory strategies to improve speech intelligibility.

Sleep and fatigue management such as education in and demonstration of energy conservation and relaxation management techniques to support health and the ability to participate in important everyday activities.

Cognitive strategies to address memory and other cognitive deficits are common during and after cancer treatment for money management, safety during meal preparation, ability to contact others/EMS, and basic medication management.

In some instances, a patient may require a tracheostomy to aid in breathing.

If so, the patient may benefit from speech evaluation and treatment and possible use of a Passy Muir Speaking Valve to allow patient to more easily communicate.

Acute care services are provided five days per week and may focus on essential ADLs such as feeding, grooming, dressing, bathing and toileting.

Teaching patients’ energy conservation techniques and use adaptive equipment to restore one’s highest level of independence in those activities may prepare a patient for discharge to home with home healthcare.

Sincerely, Ryan J. Grella, PT, DPT, OCS Director, Physical Therapy

Speech Language Pathology services are offered to both inpatients and outpatients.

Outpatient Occupational therapy is also housed on the first floor of the main hospital and may address self-care, work or leisure activities and the use of adaptive equipment or environmental modifications, including positioning and pain management strategies. It may also address home modifications and caregiver education to maximize patient safety and independence, allowing the patient to remain in the community/home.

Speech Language Pathology

Speech-language pathology is frequently consulted prior to any surgical procedure to gain baseline assessment of patient’s communication and learning skills to better plan appropriate plan of care to help patient regain speech production following surgery.

On occasion, a patient may have some difficulty in swallowing following surgery related cancer (oral, pharyngeal, laryngeal, or esophageal). A speech pathologist can assist the patient by first assessing swallow function via video swallow study, and then provide dysphagia treatment as appropriate to improve overall swallow function to allow patient to tolerate a least restrictive diet.

59

Nutrition

Enterostromal Therapy and Education

Sincerely, Bobbi Sheffield, RD, LD/N Clinical Nutrition Manager Florida Hospital North Pinellas

Post-operatively, the CWOCN teaches the patient and their significant others (if appropriate) how to manage the ostomy. These visits include education on daily management, pouch changing skills, obtaining supplies, avoiding and managing complications, odor control, travel tips and re-initiating intimacy.

Patients with compromised appetites or poor nutritional status are referred to Clinical Dietitians. They assess a patient’s nutritional status to provide optimal nutrition for the promotion of healing and quality of life. Dietitians assist patients with food preferences and tolerance before, during and after cancer treatments. The Clinical Dietitians are part of the Food and Nutrition Services Department, which provides attractive, great tasting and nutritionally balanced meals. In addition, the Clinical Dietitians participate in community events to promote healthy food habits for proper nutrition. The staff members are affiliates of the Academy of Nutrition and Dietetics and Practice groups, Dietitians in Nutrition Support, Integrative Functional Medicine and Oncology Nutrition.

The certified Wound Ostomy Continence nurse (CWOCN) is an integral part of the Cancer Care Team for the patient requiring an ostomy (an opening into the bladder or the bowel). At the request of the surgeon or patient, or when notified by the surgical scheduling team, the CWOCN usually meets with the patient both pre-and post-operatively. The preoperative visit includes provision of print and video education materials, a review of pouching options suitable for the type of stoma, and preoperative stoma marking. The pre-operative stoma marking guides the surgeon in placing the stoma in a location on the abdomen that makes post-operative care easier for the patient, and reduces the likelihood of management issues such as leaking.

Most ostomy patients are referred to home health care for follow-up, but the CWOCN remains available if the patient experiences significant issues with pouching or related issues following discharge. Contact can be made either by phone or by email; some patients have emailed pictures of their stoma or stoma site, enabling the CWOCN to provide troubleshooting or pouching tips, and occasionally sparing the patient an unnecessary office visit. Patients are also referred to local ostomy support groups if they desire ongoing emotional support.

On occasion a cancer patient will develop a non-healing wound at which time the CWOCN assists the physician in developing a management plan for the patient that is both comfortable and cost-effective.

Sincerely, Tina Baum, MS, CNS, CWOCN Wound Ostomy Continence Nurse Florida Hospital North Pinellas

 

60

Florida Hospital North Pinellas

Community Partnership with the American Cancer Society - Pinellas Unit Rosemary Giuliano, ARNP Director, Oncology Program January 1, 2013 The American Cancer Society is the nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service.

In partnership with Florida Hospital North Pinellas, the Pinellas Unit of the American Cancer Society will continue to work closely to ensure more lives are being saved from cancer and more patients being served at your hospital are being positively impacted through education and service.

In the first year of our partnership, under your leadership, Florida Hospital North Pinellas supported the American Cancer Society by contributing in excess of 300 hours of volunteer services, team fundraising, sponsorship and senior leadership support to the Relay For Life of Tarpon Springs, and by referring 16 newly diagnosed patients to our free programs and services. Because of your support, the Tarpon Springs community is better served through more resources and better educated on the importance of healthy living.

The ACS Pinellas Unit will continue to commit to the following managed through our Communities Representative and Relay Specialist; • Continued partnership of designated hospital staff to support referring newly diagnosed patients to the American Cancer Society patient services.

• Representation at Commission on Cancer meetings • Education of staff on resources available for newly diagnosed patients • 24/7 support through 1.800.227.2345 or cancer.org • Road to Recovery • Dietitian on Call • Look Good Feel Better • Support, service and recognition of team fund raising efforts In addition, we encourage your staff to utilize the American Cancer Society funding resources available to them for research and continued educational grants.

We are appreciative of Florida Hospital North Pinellas taking a precedent setting role to sponsor and lead the Tarpon Springs Relay For Life event on May 17-18 2013 which raised over $21,000 and the Kate Archer’s leadership for the Oldsmar Relay for Life event which raised over $54,000. With your leadership, this event positioned Florida Hospital North Pinellas and The American Cancer Society as liaisons to the community for increased health awareness.

Sincerely, Wendy M. Johnson Patty Riddle Area Executive Director Associate Director

61

Cancer Registry The Cancer Registry for Florida Hospital North Pinellas (FHNP) was established in 2012. In accordance with state and national guidelines, the data collected in the Cancer Registry Database includes but is not limited to demographics, cancer identification (primary site, histology, stage of disease, treatment), annual follow up and survival data. The Cancer Registry’s Database plays an important role in the collection, management and analysis of all patients with a cancer diagnosis (this includes certain primary intracranial and benign central nervous system tumors) and serves as a pathway to conduct lifetime follow up. The data is used as a clinical surveillance mechanism to review patterns of care, patient outcomes, improvement in our Oncology Program and future planning for cancer patient services. Our data is routinely reviewed for accuracy and quality before it is reported to Florida Cancer Data Systems (FCDS), Florida’s statewide population-based Cancer Registry. This provides the means for monitoring and evaluating the success of our Oncology Program. In 2012, the Cancer Registry collected a total of 328 cancer cases with 231 analytic (diagnosed and/or received all or part of first course treatment) at FHNP and 97 representing non-analytic. FHNP’s Oncology Program has seen tremendous growth with a 66% increase in the number of cancer cases reported to FCDS for 2012 and this has continued into 2013. The top five major cancer sites for FHNP this year are Lung, Skin/Melanoma, Breast, Colorectal and Bladder.

Florida Hospital North Pinellas holds a multidisciplinary Cancer Conference once a month. Cancer Conference is held the first Monday of each month from 5:00 – 7:00 pm and is CME approved. Prospective cancer cases are predominately presented along with discussion of AJCC

Staging, NCCN Guidelines and treatment options. Our multidisiplinary team has experts from each program that include but is not limited to Surgery, Pathology, Radiology, Medical Oncology, Radiation Therapy, Nursing, Oncology Research, Outpatient Services, Administration, Palliative Care and the Cancer Registry. Cancer Conferences serve both as a quality assurance tool and an educational forum. Cases presented at conference cover the entire spectrum of primary sites.

The Cancer Registry is a key component of the FHNP Oncology Program.

Registry services including data requests are shared with the Florida Hospital Tampa Bay Network which consists of highly trained Certified Tumor Registrars (CTR’s) and support staff. As a unified team, we will continue to focus on obtaining accreditation by the American College of Surgeons’ Commission on Cancer in 2015. Our sincere appreciation goes to the Cancer Committee, Oncology Program, Administration, Medical Staff, Hospital Staff and the community for their continued interest and support throughout the year.

Thank you, Cancer Registry Team Sandra Carlson, CTR – Florida Hospital Tampa Jimmie Lee Cummins, BS, CTR – Florida Hospital Tampa Randy L. Slavens, CTR – Florida Hospital North Pinellas Angela Swilley – Florida Hospital Tampa

Top Sites The top five sites of total cancer cases seen at Florida Hospital North Pinellas (FHNP) in Tarpon Springs, Florida for 2012 are displayed in the graph.

The top five sites (total cases without gender distribution) are Lung, Skin/Melanoma (excluding basal and squamous cell carcinoma), Breast, Bladder and Colorectal respectively in 2012. A majority of the cancer cases were from the primary site of lung. It’s one of the most common cancers and accounts for approximately 20% of the total cancer cases seen at Florida Hospital North Pinellas.

62

Primary Site Table Based on 2012 Statistics PRIMARY SITE

TOTAL CLASS

SEX

CS STAGE GROUP

ALL SITES ORAL CAVITY TONGUE OROPHARYNX OTHER DIGESTIVE SYSTEM ESOPHAGUS STOMACH COLON RECTUM LIVER PANCREAS OTHER RESPIRATORY SYSTEM NASAL/SINUS LARYNX LUNG/BRONCHUS BLOOD & BONE MARROW LEUKEMIA MULTIPLE MYELOMA OTHER CONNECT/SOFT TISSUE SKIN MELANOMA OTHER BREAST FEMALE GENITAL CERVIX UTERI CORPUS UTERI OVARY MALE GENITAL PROSTATE TESTIS OTHER URINARY SYSTEM BLADDER KIDNEY/RENAL BRAIN & CNS CNS ENDOCRINE THYROID LYMPHATIC SYSTEM HODGKIN'S DISEASE NON-HODGKIN'S UNKNOWN PRIMARY

328 8 3 1 4 46 4 6 24 1 2 7 2 70 1 5 64 20 6 4 10 4 57 55 2 35 11 2 6 3 17 12 4 1 36 27 9 8 8 1 1 9 1 8 6

M F 168 160 5 3 2 1 1 0 2 2 26 20 3 1 4 2 14 10 0 1 0 2 4 3 1 1 33 37 0 1 4 1 29 35 14 6 4 2 3 1 7 3 1 3 32 25 30 25 2 0 0 35 0 11 0 2 0 6 0 3 17 0 12 0 4 0 1 0 29 7 23 4 6 3 1 7 1 7 0 1 0 1 7 2 0 1 7 1 3 3

0 I II III IV UNK N/A 25 80 32 34 55 67 35 0 1 1 0 3 3 0 0 1 0 0 1 1 0 0 0 0 0 1 0 0 0 0 1 0 1 2 0 0 7 5 6 14 13 1 0 0 0 1 1 2 0 0 3 1 0 1 1 0 0 3 3 5 8 5 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 1 1 0 2 3 0 0 0 0 0 0 1 1 0 17 2 17 24 10 0 0 0 0 1 0 0 0 0 1 0 0 2 2 0 0 16 2 16 22 8 0 0 0 0 0 0 1 19 0 0 0 0 0 0 6 0 0 0 0 0 0 4 0 0 0 0 0 1 9 0 1 0 1 0 2 0 7 28 9 6 0 6 1 7 28 9 6 0 4 1 0 0 0 0 0 2 0 3 6 11 3 5 7 0 0 5 1 0 3 2 0 0 0 0 0 1 1 0 0 4 0 0 1 1 0 0 1 1 0 1 0 0 0 5 1 0 2 9 0 0 0 1 0 2 9 0 0 4 0 0 0 0 0 0 1 0 0 0 0 0 15 8 1 0 4 8 0 14 7 1 0 2 3 0 1 1 0 0 2 5 0 0 0 0 0 0 0 8 0 0 0 0 0 0 8 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 2 1 0 0 6 0 0 0 0 0 0 1 0 0 2 1 0 0 5 0 0 0 0 0 0 0 6

A N/A 231 97 6 2 2 1 0 1 4 0 33 13 3 1 6 0 16 8 1 0 2 0 5 2 0 2 54 16 1 0 4 1 49 15 9 11 5 1 3 1 1 9 1 3 48 9 46 9 2 0 25 10 8 3 2 0 4 2 2 1 6 11 1 11 4 0 1 0 22 14 17 10 5 4 5 3 5 3 1 0 1 0 7 2 1 0 6 2 6 0

63

2012 Race & Ethnicity Distribution 2012 Gender 2 2012 Gender Distribution 9 9 Distribution

2 Gender Distribution

White, Non-Hispanic

Males

Females

49%

2012 Gender Distribution

51%

49%

Males

Females

51%

49%

White, Hispanic

Males

Females

308

51%

Black Other

2012& Race & Ethnicity Distribution 2 Race Ethnicity Distribution

9 92

9 92

2012 Race & Ethnicity Distribution 2012 County at Diagnosis 2012 County at Diagnosis White, Non-Hispanic

White, Non-Hispanic White, Hispanic

9 92

Black

308

Other

White, Hispanic Black

308

111

2012 County at Diagnosis

19 5 2 17

111 153

Other 9 12

19 5 2 17

Pinellas County

Unknown

Pasco County

Out of State

Other Florida Counties

Manatee County

Hillsborough County

Hernando County

9 12

308 153

2012 Gender Distribution

Pinellas County White, Non-Hispanic Pasco County White, Hispanic Other Florida Counties Black Hillsborough County Other

2 County at Diagnosis 2012 Gender Distribution

19 5 2 Pinellas County 17 Non-Analytic Males Females 2012 Case Distribution 30% 9 2012 County at Diagnosis 51% Males 49% Females Pasco County Analytic 70% 111 12 49% 51% 19

2012 Case Distribution

2 Case Distribution

Out of State

5 2 17 Non-Analytic Hillsborough County Hernando County 9 30% 111 12 Analytic 70% 2012 Race & Ethnicity Distribution 2012Race Race&&Ethnicity Ethnicity Distribution 153 2012 Distribution 22 999 9 Other Florida Counties

153

Unknown

Manatee County

Pinellas County Pasco County Other Florida Counties Hillsborough County

Non-Hispanic White, White, Non-Hispanic

Non-Analytic

30%

Analytic

70%

White, White, Hispanic Hispanic

2012 Case Distribution 308 308

Black Black

Non-Analytic

30%

64

Analytic

70%

2012 County at Diagnosis

2012 County at Diagnosis

Other Other

Hillsborough County

153

2012 Race & Ethnicity Distribution

Hernando County

2 9 92012 Case Distribution White, Non-Hispanic

Non-Analytic

30%

Analytic 2012 Top 5 Sites at FHNP 2012 Top 5 Sites at FHNP 70%

20%

White, Hispanic

19.6%

308

Black

16.8%

Other

15% 10.7% 10% 2012 County at Diagnosis 7.6% 8.2%

19 5 2 17

5%

9 12

ng

Other Florida Counties Hillsborough County

an

M

el

B

Pasco County

Lu

as re

d d la

B

om

t

er

ta l ec

or C

ol

153

a

111 0%

Pinellas County

2012 Case Distribution 2012 Case Distribution 40% 37

35

35%

33 Non-Analytic

32

30%

30%

29

Analytic

70% 26

25

25%

20

20%

17 14 11

ys 65

v er N

U

ri

na

al

e

ry

S

rg an s O

O e

te m

0

an

0

rg

st

al

ki n

re a B Fe m

S & ve

S

e

su

of t

M on e B

&

Ti s

ar ro w

m te S

ra to ry pi

Top 5 Sites for Females Breast 6 Lung 3 Melanoma 1 0 Colorectal Benign Brain/CNS

ys

ys S

ti es ig

O

ra

ve

l

C

av i

ty

te m

Top 5 Sites for Males 10% Melanoma 5 Lung 5% Bladder 3 Colorectal 0% Prostate

M

15%

Definition of Terms AJCC Staging

American Joint Committee on Cancer’ TNM Staging & Classification system is a method for measuring the extent of disease at the time of diagnosis. Clinical and Pathological staging both are used as appropriate, based on type of cancer.

Analytic

A category or class of case which indicates that the cancer was initially diagnosed and/or treated at a specific health care facility and is eligible for inclusion in that registry’s statistical reports of treatment efficacy and survival

National Cancer Data Base (NCDB)

A clinically oriented electronic database of cancer cases submitted to the Commission on Cancer by approved cancer programs of American College of Surgeons in the United States, which can be used as a reference database to compare the management of cancer patients in one facility or region with similar patients in other regions or nationally

Non-Analytic

A patient who was diagnosed and received all of the first-course therapy at another institution, a patient who was diagnosed and/or received all or part of the first-course therapy at Florida Hospital North Pinellas before the registry’s reference date, or a patient who was diagnosed by autopsy

Primary Site

The anatomical location considered the point of origin for the malignancy

Treatment Modality

The treatment regimen planned for the patient. Single modality consists of one type of treatment; multi-modality consists of a combination of two or more types of treatment

References • •

• •

66

Cancer Facts & Figures 2012 – Published by the American Cancer Society National Cancer Database, Commission on Cancer, American College of Surgeons, National Benchmark Summary Reports Manual for Staging of Cancer, 7th Edition Florida Hospital North Pinellas – Oncology Data Services Database

Helen Ellis Memorial Foundation

Touching Lives Through Philanthropic Support The Helen Ellis Memorial Foundation and Florida Hospital North Pinellas Medical Group have continued their alliance in providing education and screening services to our community. The surgical team provides the day-to-day diagnosis, treatment and emotional support for their patients, while the Foundation develops the necessary resources for educational programs and screenings in our community.

During the past year, the Foundation: • Provided the surgical team opportunities to speak to various community groups, discussing early skin cancer detection, diagnosis and treatment of various cancers.

• Continued support of the Oncology Internship program to provide stipend assistance to students.

• Dedicated all proceeds from “Doctor Idol Tampa Bay” and a direct mail campaign to fund “Operation Sunshine”, Florida Hospital’s mobile unit for melanoma and other skin cancer education and screenings benefitting our community.

Yours truly, Terry B. Smither Executive Director Helen Ellis Memorial Foundation In support of Florida Hospital North Pinellas

67

Looking Forward • • • • •

68

Expand the scope of patient education and navigation Develop and initiate a lung cancer screening program Attain the American College of Surgeons’ Commission on Cancer accreditation Develop an Oncology Resource Room for patients and staff Form a multi-campus Telemedicine Oncology Conference Series

ONCOLOGY

2013 annual report

1395 South Pinellas Avenue | Tarpon Springs, Florida 34689 (727) 942-5000 | FHNorthPinellas.com