April 2017 & May 2017
Cancer Stakeholder Florida Department of Health, Comprehensive Cancer Control Program
PROGRAM SPOTLIGHT:
Florida’s oropharyngeal cancer rates are among the highest in the country NATIONAL ORAL, HEAD AND NECK CANCER AWARENESS WEEK (APRIL 12–18)
I
n Florida, there were 4,517 new cases and 1,040 deaths of oral, head and neck cancers in 2013. Several promising efforts in preventative practices seek to reduce this stable incidence rate (17–18 per 100,000 age adjusted). Cancers in this area of the body are usually caused by tobacco and alcohol; however, recent studies show about 63 percent of oropharyngeal cancers, those in the back of the throat, base of the tongue and tonsils, are caused by human papillomavirus (HPV). On average, men are three times more likely to get oral HPV related cancers than women. The Centers for Disease Control and Prevention (CDC) estimates that in the U.S. there are more than 2,370 new cases of HPV—associated oral cancers diagnosed in women and nearly 9,356 are diagnosed in men each year. These numbers are based on cancers in specific areas of the oropharynx and do not include cancers in all areas of the head and neck or oral cavity. Should this trend continue, by 2020 the number of HPV–positive oropharyngeal cancers in the U.S. will surpass cervical cancers. HPV-related infections and cancers can be prevented through vaccination. HPV vaccines prevent an initial infection with the most common types of HPV found in oropharyngeal cancers. The vaccine, a two shot series if younger than 15 years or three shot if older than 15 years, is recommended for both boys and girls starting at 9 years of age and through the age of 26 for those who did not get any or all of the shots when they were younger. For more information, visit the CDC’s website for head and neck cancer statistics or to see maps of HPV—associated oropharyngeal cancer by state. Medical providers are encouraged to visit the CDC’s Preteen and Teen Vaccines website which includes patient handouts and other useful information. In addition, parents and young adults are also encouraged to visit Diseases and the Vaccines that Prevent Them to learn more about vaccine–preventable diseases and recommendations. May is National Skin Cancer Awareness Month Skin cancer is the most preventable form of cancer, yet it disproportionately affects youth and has the largest incidence of any cancer group. In Florida, 5,535 new melanoma cases, the deadliest and only reportable skin cancer, were diagnosed in 2012. The 2015 Youth Risk Behavior Survey found that nine in ten Florida public high school students (91.2%) did not wear sunscreen most of the time or never when outside for more than one hour on a sunny day. Furthermore, some students (6%) sought out exposure using an indoor tanning device, such as a sunlamp, sunbed, or tanning booth, one or more times during the past 12 months. Estimates on average treatment costs for a patient with pre-cancerous or nonmelanoma skin cancer range from around $200 to $4,558 and
patients with melanoma range from $1,732 to $56,059 based on the cancer stage.1,2,3 Reducing unprotected exposure to ultraviolet (UV) light from sun and tanning beds can help limit the cumulative effects of this dangerous carcinogen. Exposure to UV light from tanning beds before age 25 greatly increases the risk of basal cell and squamous cell skin cancers.3 The recommendation is to avoid outdoor exposure when the sun’s rays are the strongest, between 10:00 a.m. and 4:00 p.m. When exposure cannot be avoided, cover up from the sun’s harmful rays with articles of clothing (such as hats and swim shirts) and sunscreen with SPF 30 to 50. Sunscreen should be reapplied every two hours. The Surgeon General of the United States’ Call to Action to Prevent Skin Cancer highlights how policies that address skin cancer prevention vary across the country. Some states, such as California and New York, have passed legislation restricting tanning beds to those under age 18, as well as requiring that schools allow students to use sun-protective clothing or sunscreen, while other states, such as Arizona and Kentucky, have passed legislation to support sun-safety education programs and skin cancer prevention awareness. Organizations and institutions can consider the Community Guide recommendations for skin cancer education and policy approaches. For more information on skin cancer statistics and materials visit Centers for Disease Control and Prevention, National Cancer Institute, or the American Academy of Dermatology. 1. Higashi, Veenstra, Langley. Health Economic Evaluation of Non-Melanoma Skin Cancer and Actinic Keratosis. 2. Losina, Walensky, Geller, et al. Visual Screening for Malignant Melanoma: A Cost-effectiveness Analysis. 3. Seidler AM, Pennie ML, Veledar E, Culler SD, Chen SC. Economic Burden of Melanoma in the Elderly Population: Population-Based Analysis of the Surveillance, Epidemiology, and End Results (SEER)–Medicare Data.
April 2017 & May 2017 Cancer Stakeholder
State Update Spring Application Cycle for Cancer Center of Excellence Began March 15, 2017
Tobacco Free Florida Marks 10 Years of Life-Saving Program
S
pring 2017 marks 10 years since the Tobacco Free Florida’s program launch following Floridians overwhelming vote in support of a state constitutional amendment to fund a tobacco education and use prevention program. In 2006, the smoking rate was flattening and the state was spending billions of dollars on health care costs. Further, Florida was receiving money from its lawsuit settlement with tobacco companies, but only a small percentage was being spent on a tobacco control program. By mandating the creation of Tobacco Free Florida, Florida voters ensured that a comprehensive program benefitting Floridians’ health and the state’s finances would be funded by 15 percent of the annual settlement amount– not taxpayer dollars. This year’s Tobacco Free Florida Week, taking place May 7–13, is an opportune time to recognize our state’s progress in reducing tobacco use. Tobacco Free Florida is truly a public health success story having had a positive–lifesaving–impact on so many Floridians. Tobacco Free Florida’s impact is proven in numbers: Fewer young people have
started smoking since Tobacco Free Florida was created. The youth smoking rate has decreased from 10.6 percent in 2006 to 3 percent in 2016–an astounding 71 percent decrease. In 2006, the adult smoking rate was 21 percent. In 2015, it
stands at 15.8 percent–the lowest it has ever been. Since 2007, Tobacco Free Florida’s free quit services have helped more than 159,000 Floridians quit tobacco. The program saved the state $3.2 billion in health care costs in 2015. Annual smokingrelated health care costs in Florida decreased 15 percent from 2006 to 2015 as a result of fewer adults smoking. While the program has made remarkable progress, there is still work to be done. In fact, tobacco remains the leading cause of preventable disease and death in Florida and the United States. The tobacco industry is constantly finding new ways to target vulnerable populations, and more of our youth are experimenting with a range of new options rather than using traditional products such as cigarettes. Tobacco continues to be a costly addiction and costs many Floridians their health, their money and their time with friends and family. The Bureau of Tobacco Free Florida has unwavering passion and commitment to protect Floridians from tobacco and nicotine addiction, to improve the health and wellbeing of our residents and thus save taxpayers billions more in health care costs. Together, we can strive for a truly tobacco free Florida. To learn more about the true cost of smoking, visit tobaccofreeflorida.com /costofsmoking.
Cancer Centers of Excellence designation recognizes organizations for demonstrating commitment to excellence by providing patientcentered coordinated care for those undergoing cancer treatment and therapy in Florida. One purpose of the Cancer Centers of Excellence Program is to support efforts to obtain and sustain National Cancer Institute designation of Florida programs as Comprehensive Cancer Centers. The Cancer Center of Excellence Designation will recognize providers that exceed service standards and excel in providing quality, comprehensive and patientcoordinated care. In the fall of 2016, the Joint Committee, comprising members from the Biomedical Research Advisory Council and the Cancer Control and Research Advisory Council, met to review the application criteria and recommend updates. The following changes were made: A substantive change was proposed to address concerns of nonacademic community centers related to the type and scope of research involvement required. The change was recommended related to the requirement for research participation. Centers will now be required to (a) have evidence of active involvement in clinical research, (b) evidence of national impact in one of six designated research areas and (c) evidence of research in at least one other designated research area. Several sections were modified to improve clarity and update links to resources. Past recipients include the H. Lee Moffitt Cancer Center and Research Institute, Mayo Clinic Florida, University of Miami Sylvester Comprehensive Cancer Center and University of Florida Health Cancer Center, which includes University of Florida Health Shands Hospital, University of Florida Health Proton Therapy Institute and Orlando Health's Orlando Regional Medical Center. Centers interested in applying can visit the Department of Health website. For more information contact Bonnie Gaughan-Bailey, Biomedical Research Administrator, at 850-245-4444 extension 2240 or by email at Bonnie.Gaughan-Bailey@flhealth.gov.
Florida’s 2017 Legislative Session Florida’s 2017 Legislative Session convened on Tuesday, March 7, 2017 and will continue for 60 days, adjourning on May 5, 2017. Current bills that may influence cancer control efforts: Senate Bill 228: Physician Orders for Life-sustaining TreatmentEstablishing the Physician Orders for Life-Sustaining Treatment (POLST) Program within the Department of Health; providing limited immunity for legal representatives and specified health care providers acting in good faith in reliance on POLST forms; authorizing emergency medical transportation providers to withhold or withdraw cardiopulmonary resuscitation or other medical interventions if presented with POLST forms that contain an order not to resuscitate, etc. Senate Bill 526: Mammography Reports-Requiring that mammography reports include a specified notice regarding breast density, etc. See State Update, pg. 7
2
April 2017 & May 2017 Cancer Stakeholder
Plans Are Essential Cancer Survivor Tips
lanning for a disaster is crucial for cancer survivors, especially for those who become displaced. Those on active treatment and/or with a weakened immune system are at a higher risk for infections, bleeding, fatigue and injury. To prepare for disaster and stay safe, cancer survivors should develop a comprehensive plan which includes:
P
Speaking with their health care provider about what to do and how to stay in contact in the event of a disaster, including what to do if it becomes impossible to get to a scheduled radiation treatment or chemotherapy. Developing a support network with family, friends, neighbors, co-workers and school personnel in the case of a disaster event. Knowing the exact diagnosis, cancer stage and any medications currently being taken. If receiving chemotherapy or radiation, know at which point during the treatment cycle. If undergoing chemotherapy and staying at shelter, protecting from infection by hand washing with alcoholbased hand sanitizer if water is not available, and wearing a mask (including a NIOSH-Approved N95 Particulate Filtering Facepiece Respirator) is important. If in a clinical trial, knowing the trial number (NCT number, preferably), Principal Investigator, hospital and drugs or treatments being given.
Keeping contact information for the health care provider and other important phone numbers including the insurance company and the pharmacy. Cell phones may not work and batteries can drain, so it is important to write down phone numbers and other health care information. For those with insurance, carrying the insurance card and contact the insurance provider in the event displacement or in need of care. Making a kit with important items like dressings, antiseptic, medications, a thermometer, etc. Put them in a zip closure bag to keep them dry. Wearing a medical alert bracelet or carrying other identiďŹ cation. In the case of illness while in an emergency shelter, ďŹ rst responders will know how to better assist. Keeping copies of the plan in multiple locations such as the home, car, with other members of a personal support network, on a USB drive, and/or smartphone. Signing up to receive emergency alerts through the county or town. Visiting FLGetAPlan.com to learn more about how to prepare in the event of an emergency and develop an individual disaster plan.
3
April 2017 & May 2017 Cancer Stakeholder
Educate Patients about Cancer Prevention
ealthiest Weight Florida encourages health care providers and professionals to educate their patients about detecting and preventing skin cancer during outdoor activities. The two most common types of skin cancer are basal cell and squamous cell carcinomas. Although they are highly curable, they can be disfiguring and costly. Melanoma, the third most common skin cancer, is more dangerous and causes the most deaths.1 The majority of these three types of skin cancer are caused by exposure to ultraviolet (UV) light.
H
Healthiest Weight Florida is a public-private collaboration bringing together agencies, institutions, organizations and communities to help Floridians make more informed choices about active lifestyles and healthy eating.
1. American Cancer Society (2017). What is Skin Cancer? Retrieved from https://www.cancer.org/cancer/skincancer/prevention-and-earlydetection/what-is-skin-cancer.html 2. Center for Disease Control and Prevention (2017). Skin Cancer. Retrieved from https://www.cdc.gov/cancer/skin/index. htm 3. USDA Choose My Plate (2017). Why is it Important to Eat Vegetables? Retrieved from https://www.choosemyplate.gov/vegeta bles-nutrients-health
4
May is National Skin Cancer Detection and Prevention Month. To protect skin from ultraviolet rays and lower the risk of developing skin cancer stay in the shade, or indoors, during midday hours, wear clothing that covers your arms and legs, wear a hat or visor to protect your face, ears and head, wear sunglasses while outdoors to block UVA and UVB rays,
avoid tanning beds and apply sunscreen when outdoors for an extended period of time.2 Proper nutrition can help keep the skin healthy and protected as well. Vitamin deficiencies can lead to adverse effects for the skin because they play an important role in protecting the skin from sun damage, including skin cancer. Vitamin C, D and E are all important for skin health. Vitamin C can enhance the effectiveness of sunscreens applied to the skin for protection from the sun’s harmful UV rays. Vitamin D helps create healthy skin cells, where it plays an important role in skin tone. Vitamin E is an antioxidant and one of its main functions in skin care is to protect against sun damage.3 Healthiest Weight Florida encourages all Floridians to engage in healthy lifestyle behaviors such as healthy eating, active living and taking precautions in order to help detect and help prevent skin cancer.
April 2017 & May 2017 Cancer Stakeholder
Cancer In the News General Cancer Related Articles
Access to Care Related Articles
Survivorship Related Articles
Death rates from cancer will fall faster in men than in women in Europe in 2017—
How are calluses and throat cancer related?—MNT, Feb. 4, 2017
Cancer: New method tags elusive tumors for targeted therapy—MNT, Feb. 15, 2017
Broad cancer vaccine may be out of reach—
American Cancer Society endorses twodose regimen for HPV vaccination—Science
NCI launches study of African-American cancer survivors—National Cancer Institute
Science Daily, Feb. 23, 2017
Daily, Feb. 7, 2017
(NCI), Feb. 27, 2017
Colorectal Cancer Statistics, 2017—
Study finds no evidence of common herpes type virus in aggressive brain cancer tissue—Science Daily, Feb. 28, 2017
Study finds single, escalated dose of brachytherapy radiation may be a safe and effective treatment for localized prostate cancer—Science Daily, March 1, 2017
Medical News Today (MNT), Feb. 22, 2017
American Cancer Society, March 1, 2017 Metastatic lung cancer: Symptoms, diagnosis, and treatment—MNT, March 16,
2017
Cancer Screening Test Use—United States, 2015—CDC, March 1, 2017
Prevention Related Articles
Lung cancer and shoulder pain: What's the connection?—MNT, March 14, 2017
Who gets sunburned? Survey finds risk is greater for young adults with melanin-rich skin—Science Daily, Feb. 27, 2017
New alternative to colonoscopy is as easy as swallowing a pill—MNT, March 15, 2017
Tanning devices cost US healthcare $343 million a year—Science Daily, Feb. 28, 2017
Significant increase in number of women tested for BRCA gene, but many high-risk patients still missing out—Science Daily,
US workers without paid sick leave more likely to forego preventive health care—
Science Daily, March 1, 2017
March 22, 2017 Largest ever brain cancer study reveals new secrets to inherited risk—Science Daily,
Poor adolescent, early adult diet associated with increased risk for pre-menstrual breast cancer—Science Daily, March 1, 2017
March 27, 2017
New research shows gluten contributes to the development of a very rare, but deadly, blood cancer in a small group of celiac patients—Science Daily, March 1, 2017
2017
6 Steps to Protect Yourself from Colorectal Cancer—American Institute for Cancer
Prostate screening often occurs without discussion of benefits, risks—Science Daily,
New finding could lead to earlier liver cancer diagnosis—Science Daily, March 27, Major genetic study identifies 12 new genetic variants for ovarian cancer—
Science Daily, March 27, 2017
Research (AICR), March, 3, 2017
March 28, 2017
How does broccoli help prevent cancer? Study sheds light—MNT, March 18, 2017
Mammography vs. thermography: Comparing the benefits—MNT, March 29,
Vitamin D, calcium supplementation among older women does not significantly reduce risk of cancer, study finds—Science
2017
Daily, March 28, 2017
Vitamin C can target and kill cancer stem cells, study shows—MNT, March 13, 2017 Mechanism triggering spread of prostate cancer to bones found—Science Daily,
March 13, 2017 Targeting cancer stem cells improves treatment effectiveness and prevents metastasis—MNT, March 13, 2017 1 in 5 patients with breast cancer could benefit from existing treatment, genetic study reveals—MNT, March 14, 2017 Reducing radiation could safely cut breast cancer treatment costs—MNT, March 14,
2017 Scripps Florida scientists develop new drug delivery method for cancer therapy—MNT,
March 20, 2017 Stem-Cell Based Tool May Help Measure Heart Toxicity of Cancer Drugs—NCI, March
21, 2017 Scientists find possible achilles heel of treatment resistant cancers—MNT, March
21, 2017 Breast cancer: Study identifies a molecular mechanism of drug resistance in ER+ tumors—MNT, March 21, 2017 Less invasive hysterectomy for early-stage endometrial cancer finds clinical support—
Science Daily, March 28, 2017 More women opting to remove a healthy breast after cancer diagnosis—MNT, March
29, 2017
5
April 2017 & May 2017 Cancer Stakeholder
Tools & Resources CancerCare presents the following Connect® Education Workshops (all are from 1:30–2:30 p.m. ET): All sessions are free and preregistration is required. May 5: Advances in the Treatment of Renal Cell Cancer Participate by listening to these workshops on the telephone or via live streaming through the Internet. For more information or to register online, visit CancerCare online or call 1-800-813-HOPE (4673). Listen to past Connect Education Workshops as podcasts through CancerCare's website. The National Comprehensive Cancer Network’s (NCCN) Continuing Education Program seeks to improve patient outcomes in oncology by educating clinicians on the application of evidence-based medicine. Their accredited educational activities are designed for oncologists (in both community and academic settings), nurses, pharmacists, case managers, and other health care professionals involved in the care of patients with cancer. April 7: A Multidisciplinary Approach to Individualized Patient Care-Peripheral T-cell Lymphomas April 12: Breast Cancer with Updates from the 2016 San Antonio Breast Cancer SymposiumAdjuvant Radiation Therapy in Early Stage Breast Cancer Sessions are approved for AMA PRA Category 1 Credit(s)™ as identified. The Patient Advocate Foundation hosts patient empowerment webinar series to build patients’ skills and increase access to health care.
April 21: Clinical Trials: A Pathway to Cutting
Edge Treatments, 3:00–4:00 p.m. ET Cancer and Careers is hosting an educational series for health care professionals (all are from: 1:00–2:00 p.m. ET unless otherwise noted) that covers practical and legal issues concerning balancing work and cancer. All sessions are free and pre-registration is required. One continuing education credit will be provided free of charge to eligible oncology nurses and social workers upon approval from listed agencies. June 7: Career Change Sept. 13: Disclosure, Privacy & Online Brand Oct. 11: Working Through Treatment The CDC’s Division on Cancer Prevention and Control is providing online continuing medical education (CME) opportunity and health care provider resources as part of the Bring Your Brave campaign to educate young women and providers on hereditary breast and ovarian cancer risk. CDC also released a two guides: Policies and Practices for Cancer Prevention and Survivorship: Physical Activity and New Hampshire Colorectal Cancer Screening Program Patient Navigation Model. Each provide ideas on collecting and analyze data, measure effects, strategies for increasing physical activity or cancer screening and resources to support community strategies. The Community Guide released Insufficient Evidence Findings User Guides for public health practitioners, researchers and funders to understand what insufficient evidence means and how it can be used. Florida Department of Health released a video on how Florida is leading the nation in tobacco prevention and cessation.
State Update from pg. 2 Senate Bill 998: Cigarette Surcharge and Tax-Revising the amounts and applicability of the cigarette surcharge and tax, respectively, which are levied upon the sale, receipt, purchase, possession, consumption, handling, distribution, and use of cigarettes; deleting provisions that authorize the Division of Alcoholic Beverages and Tobacco of the Department of Business and Professional Regulation to authorize manufacturers to distribute specified free sample packages of cigarettes without affixing surcharge and tax stamps under certain circumstances and that provide the basis for a certain surcharge and tax, etc. The Department does not take a position on pending legislation. For more information, visit Online Sunshine.
6
Funding Opportunities American Cancer Society is soliciting applications for patient-oriented research in palliative care. Applications are for pilot or exploratory research grants in palliative care of cancer patients and their families. Click here to learn more. Closing date 4/1/17. Florida Breast Cancer Foundation is offering education grants for Florida organizations for projects in a single county and multiple counties in oneon-one or small group settings. Click here to apply. Closing date 5/1/17. New Informatics Tools and Methods to Enhance U.S. Cancer Surveillance and Research is a FOA to support tools and methods to facilitate data extraction from medical records, approaches for integration of registry and medical data and approaches for ongoing reporting to registry data flow. Click here to apply. Closing dates 4/14/17 and 11/30/17. Mechanisms of Disparities in Chronic Liver Diseases and Cancer is a FOA to support multidisciplinary exploratory and developmental research to understand etiologic factors and mechanisms that result in disparities in chronic liver diseases and cancer. Click here to apply. Closing dates 5/22/17, 4/4/18 and 4/4/19. Examination of Survivorship Care Planning Efficacy and Impact is a FOA to stimulate research that will develop and test metrics for evaluating the impact of survivorship care planning on cancer survivors' morbidity, self-management and adherence to care recommendations. Click here to apply. Closing date 6/5/17 and 10/5/17.
Department of Health and Human Services released a FOA to scale and spread existing clinical decision support as well as disseminate and implement findings from PatientCentered Outcomes Research into Clinical Practice. Click here to apply. Closing date 5/25/17. Agency for Healthcare Research and Quality released a FOA for research projects to develop, test and evaluate measures of shared decision making for research in clinical settings. Click here to apply. Closing dates 6/5/17 and 10/5/17.
April 2017 & May 2017 Cancer Stakeholder
About the Cancer Stakeholder
Events 2017 Esri Public Sector GIS Conference in Palm Beach on April 11–13, 2017 Joining FORCEs Against Hereditary Cancer in Orlando, Fla. on June 8–10, 2017. Advanced Renal Cell Carcinoma: Combination, Sequential Strategies, and Immunotherapies in Philadelphia, Pa. on March 8, 2017.
Collaboratives R
egional Cancer Control Collaboratives exist across the state and work to bring public and private partners together to reduce the burden of cancer. For information about what your regional collaborative in your area is doing, visit their websites listed below.
> Northwest Florida Cancer Control Collaborative
NCCN Policy Summit: Ensuring Patient Access and Safety in Cancer Care in Washington, D.C. on June 15, 2017.
> Northeast Florida Cancer Control
CDC National Cancer Conference: Visualizing the Future through Prevention, Innovation and Communication in Atlanta, Ga. on August 14–16, 2017.
> >
2017 Cancer Programs Conference: Creating a Culture of Quality in Chicago, Ill. on Sept. 8–9, 2017.
>
Changing Patterns of Cancer in Native Communities: Strength through Tradition and Science in Niagara Falls, N.Y. on Sept. 21–24, 2017.
>
NCCN Policy Summit: Redefining Quality Measurement in Oncology in Washington, D.C. on Sept. 25, 2017. NCCN 12th Annual Congress: Hematologic Malignancies™ in San Francisco, Calif. on Oct. 7, 2017. NCCN Patient Advocacy Summit: Addressing Survivorship in Cancer Care in Washington, D.C. on Dec. 1, 2017.
>
Collaborative Facebook: NEFCCC North Central Florida Cancer Control Collaborative East Central Florida Cancer Control Collaborative Southeast Florida Cancer Control Collaborative Facebook: SoFla Fighting Cancer Southwest Florida Cancer Control Collaborative The Southeast American Indian Council (SEAIC) focuses on needs assessments, preventive education and quality of life for American Indians. Membership is open to anyone of American Indian heritage. Email Dewey Painter or call him at (904) 2080857 for an application or for more information.
To be added to the contact list for any of these collaboratives, send an email request to Cancer@flhealth.gov.
The Cancer Stakeholder is an e-newsletter, which includes the DOH cancer updates, cancer tools and resources, funding opportunities, events, research, and other information about cancer. The opinions expressed in the Cancer Stakeholder do not necessarily reflect the views of the Department or its staff. Please direct questions, comments and suggestions to the Comprehensive Cancer Control Program at cancer@flhealth.gov. If you would like to be removed from this distribution list, please send an email with “Unsubscribe” written in the subject line to cancer@flhealth.gov. Please type in the body of the email the county where you reside. Please understand that unsubscribing from the Cancer Stakeholder will unsubscribe you from receiving future emails related to the Comprehensive Cancer Control Program, the Regional Cancer Control Collaboratives and the associated local and statewide cancer activities. This electronic newsletter was funded by Cooperative Agreement U58/DP003872 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. For any questions or concerns regarding this newsletter or to include your information in a future issue: Sam.Mooneyhan@ flhealth.gov (850) 245-4444, ext. 3857
7