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Baptist Cancer Institute 2013 CA N C ER P ROG RA M Annual Report Table of Contents 4 Cancer Committee Report 8 Tumor Registry Report 20 Tumor Review: Anal Cancer 24 Tumor Review: Chronic Myelocytic Leukemia 28 Quality Assurance 30 Clinical Research and Education Baptist Cancer Institute 2013 Annual Report Baptist Cancer Institute is one of the most active Health, the only locally governed, faith-based health clinical research institutes in the state of Florida, system in Northeast Florida. Baptist Health, a with open studies in breast cancer, lung cancer, Magnet™ Health Care System honored for excellence gastrointestinal malignancies, lymphoma, leukemia, in patient care, is comprised of Baptist Medical head and neck cancer and brain tumors. We work in Center Jacksonville, Baptist Medical Center Beaches, collaboration with physicians across the state and the Baptist Medical Center Nassau, Baptist Medical nation to conduct clinical trials that lead to improved Center South, Wolfson Children’s Hospital and Baptist diagnostic approaches, reductions in toxicities and Clay Medical Campus. new ways to fight these often devastating diseases. 3 Baptist Cancer Institute 2013 Annual Report Baptist Cancer Institute (BCI) is affiliated with Baptist Cancer Committee Report Troy H. Guthrie Jr., MD, Cancer Committee Chairman Similar to last year, the Baptist Cancer Institute Annual Report for the year 2012 at Baptist Hospital Systems will be electronic. This follows a trend used by most hospital systems throughout the nation. For the second year, the Cancer committee report will be accessible at the Baptist Health System website for review. This year the cancer program has continued to be healthy offering a wide breadth of services and high quality care for patients throughout Northeast Florida and Southeast Georgia. Cutting edge programs in neuro-oncology, breast care, as well as active clinical research in the fields of medical oncology and radiation oncology are offered to physicians and their patients for participation. The development of a palliative care program as well as close communication with Hospice of Northeast Florida allows a continuity of care for patients moving from active treatment towards supportive care only. These palliative care programs allows the patients and their families to make every minute count towards the highest quality of life and to enjoy, hopefully, most of their Baptist Cancer Institute 2013 Annual Report time within the home setting. Clinical research programs cancer program. This is mandated by the American continue to be active with research programs in breast College of Surgeons and the Commission on Cancer. cancer, lung cancer, melanoma, brain tumors, prostate At each meeting, the activities of Tumor Registry and cancer, hematologic malignancies, as well as radiation current clinical research as well as goals of the Cancer therapy. Research studies are offered through the Committee are reviewed. Current leadership for the auspices of both National Cancer Institute clinical study Cancer Committee include Troy H. Guthrie, Jr., MD, groups as well as pharmaceutical programs. Screening chairman, Cancer Committee; Mark Augspurger, programs in breast cancer, colon cancer, prostate cancer MD, liaison to the American College of Surgeons; and skin malignancies continue to be offered by both Patricia Wood, RN, BSN, OCN, quality improvement private physicians as well as the hospital system. The coordinator; Paul Oberdorfer, MD, community outreach Genetics Assessment program under the leadership of coordinator; and Melissa McCarthan, RHT CTR, Tumor Melinda Fawbush, MSN, ARNP continues to expand Registry. At each meeting the committee reviews, and has recruited grants for underserved patients. Multi- revises and reapproves current program goals to disciplinary conferences in breast cancer are offered determine whether they are being met and if they are weekly at Baptist Jacksonville and at longer intervals by aligned with the latest requirements of the American the other Baptist hospitals. The lung cancer conference College of Surgeons. This Annual Report, as required is bi-weekly and the neuro-oncology conference is by the American College of Surgeons, will include monthly. These programs are teleconferenced to prospective and retrospective studies of two cancer satellite hospitals so that education and discussion can primary sites as well as assessment of the quality of be received by those physicians and health care staff in data provided to review those sites by the Tumor their own hospital. Psycho-social support continues to Registry. This year anal cancer and chronic myelocytic be offered by George Royal, PhD, and more recently leukemia will be the areas of review. In 2012, more nutritional, physical therapy and occupational therapy than ten percent of all analytical cases were reviewed programs are offered primarily to our breast cancer on a prospective basis by physicians who volunteered patients and are open to all hospitals for referral. as required by the American College of Surgeons The Cancer Committee at Baptist Medical Center to ensure continued quality and timeliness of data Jacksonville continues to meet quarterly to provide submitted into the Tumor Registry. In 2012, the total leadership, direction and review of all aspects of the number of all analytic cases was 1,625. Currently, Baptist Cancer Institute 2013 Annual Report 5 40 to 50 protocols were offered throughout the campus 28,000 analytic cases since 1990. (Figure 1) The Cancer for patients to be entered into clinical research. In 2012, Clinical Research program includes active participation an evolving trend is that over 50 percent of the cases in the Eastern Cooperative Oncology Group, Radiation were entered into pharmaceutical trials compared to Therapy Oncology Group, Mayo Clinic Cancer Research past years when the number of NCI group sponsored Consortium, as well as pharmaceutical sponsored and pharmaceutical trials were approximately equal. research trials. At any one time in 2012, approximately As Cancer Committee Chairman since 2005, it gives me great pleasure to see the 6 continued expansion of cancer services offered at Baptist Jacksonville and at satellite hospitals. State-of-the-art programs which run the gamut from hematologic to solid tumor malignancies are being offered in a multi-disciplinary approach to patients of all walks of life. This has been brought forth through a close collaboration of physicians, hospitals administrators, and allied professional staff which has enabled the Baptist Cancer Institute to remain at the forefront of cancer care in this region. Troy H. Guthrie Jr., MD Cancer Committee Chairman Medical Director, Education and Research Baptist Cancer Institute 2005 1656 1625 2004 1624 1253 1138 1265 1999 1139 1308 1998 1041 972 1996 965 1995 865 1102 928 800 807 1000 764 1004 1200 688 N o . of Pa t ient s 1600 1400 1779 1467 1630 1800 1744 Fi gu re 1 Baptist Cancer Institute Analytic Cases by Year 964 Baptist Cancer Institute 2013 Annual Report with those cases, the Tumor Registry has accrued over 2011 2012 600 400 200 0 1990 1991 1992 1993 1994 1997 2000 Yea r 2001 2002 2003 2006 2007 2008 2009 2010 Baptist Cancer Institute 2013 Annual Report 7 Tumor Registry Report Troy H. Guthrie Jr., MD, Cancer Committee Chairman Melissa McCarthan, RHIT, CTR April Stebbins, RHIT, CTR Rassy Sprouse, BSc The cancer program at Baptist Cancer Institute (BCI) continues to maintain a preeminent position in Northeast Florida and Southeast Georgia. The program is a multi-faceted unit designed to meet the important needs of the public and medical community. Baptist Cancer Institute is housed at the Williams Cancer Center a few blocks from the Baptist Jacksonville campus. However, with the use of telecommunications, conferences and programs have been developed in the affiliated hospitals at Baptist South, Baptist Beaches, and Baptist Nassau. BCI is approved as a community hospital comprehensive program by the American College of Surgeons; the most recent audit was in 2011 and an upcoming audit is in February 2014. BCI’s interest in leadership in cancer care, education and clinical research are recognized throughout the community. Programs have been developed that include breast, prostate, colorectal and skin cancer screening for those common cancers. Other major assets of the Baptist Cancer Baptist Cancer Institute 2013 Annual Report Institute include the most comprehensive digital sites needed to remain certified by the American based telecommunication screening program for College of Surgeons. In 2012, the Cancer Registry of breast cancer. This program is preeminent within the Baptist Cancer Institute added 1,625 new analytical geographic area. Other major programs include a cases to the preexisting cancer database that has Brain Tumor multi-disciplinary program; preeminent resulted in a total accumulation of 28,039 cases over melanoma treatment including biologics as well a span of 23 years. Currently, the Tumor Registry as surgery and radiation; genetic risk assessment analyzes cases from Baptist Jacksonville, which it has programs; psycho-social support and quality of life been doing since 1990 as well as those cases from programs including palliative care. Nurse navigator Baptist South which has been accumulated since 2005. their diagnosis and care exist in breast and lung cancer. Post-treatment programs in nutrition, physical therapy, psycho-social support and pain management are an active facet of our program. The 1,625 cases seen in 2012 are the same as was seen in 2011 (1,624.) As in previous years, there was a female predominance with 956 cases of 1,625 being female and 669 cases being male (Figure 2). This strong female predominance represents the high The Cancer Committee of Baptist Health meets number of both breast cancer and Gyn malignancies quarterly and provides leadership, directions, and seen at Baptist Health system. Table 1 demonstrates a review of overall activities. Currently, the Cancer the primary sites seen at Baptist Cancer Institute Committee represents all active disciplines both downtown. The five most common sites include breast medical and supportive care. Annually, the committee (27 percent) with a total of 440 cases; lung (15 percent) reviews and reapproves its objectives and the newest with 238 cases; prostate (9 percent) with 155 cases; recommendations from the American College of female genital cancer (7 percent) with 116 cases and Surgeons. Direct supervision is provided over BCI’s colorectal cancer (5 percent) with 87 cases, which was cancer conferences, cancer registry, quality control essentially tied with brain and CNS with 86 cases or 5 data, quality improvement of cancer related issues percent. Table 2 demonstrates the primary sites seen and community outreach. Each year the Cancer at Baptist Medical Center South which is somewhat Committee approves two goals to be addressed in different with breast at 148 cases or 26 percent and the quality improvement program, one retrospective lung at 65 cases with 11 percent being the two most and one prospective. Each year the Baptist Tumor common sites. Colorectal was at 49 cases or 9 percent, Registry’s data is reviewed by physicians for quality of thyroid at 46 cases or 9 percent, urinary bladder at data. Ten percent of all cases are personally reviewed 41 cases or 7 percent and kidney cancer at 35 cases by physician volunteers. Prospective case analyses or 6 percent. which is different than that seen at on breast cancer and lung cancer as well as brain are Baptist Jacksonville. This represents most probably reviewed in sub-specialty conferences. The Tumor the colorectal surgery presence as well as endocrine Board reviews in terms of prospective case analysis surgery and urology presence at Baptist South. most of the other malignancies and covers all primary 9 Baptist Cancer Institute 2013 Annual Report programs to assist patients throughout all aspects of 669 1000 800 Table 1 Primary Sites : Baptist Medical Center Jacksonville (2012) 956 2012 (Baptist Jacksonville) N o . of Ma l i gn a nci es Baptist Cancer Institute 2013 Annual Report 10 Figu re 2 Male & Female Malignancies: 600 400 200 0 Mal e Female Site Total % Male Female Breast 440 27% 3 437 Lung 238 15% 119 119 Prostate 155 9% 155 0 Female Genital 116 7% 0 116 Colorectal 87 5% 53 34 Brain & CNS 86 5% 46 40 Melanoma 65 4% 37 28 Kidney 58 4% 33 25 Other Sites 57 4% 30 27 Lymph Node 52 3% 26 26 Urinary Bladder 47 3% 41 6 Blood & Bone Marrow 43 3% 23 20 Pancreas 41 3% 25 16 Unknown Primary 31 2% 18 13 Head & Neck 30 2% 21 9 Stomach 28 2% 13 15 Thryoid 24 1% 7 17 Liver 20 1% 15 5 Esophagus 7 0% 4 3 1,625 100% 669 956 Total Table 3 illustrates the difference in prevalence patterns malignancy, only 9 percent were seen at Baptist Cancer of the Baptist Cancer Institute compared to Florida and Institute compared to 15 percent in both Florida and the United States SEER data. As you can see, breast the United States SEER data. Female genital cancer at cancer with 27 percent is far above that seen in Florida, 7 percent at BCI is markedly increased compared to 3 13 percent, and in the United States, 14 percent. percent in Florida and 5 percent in the United States. Lung cancer, the second most common malignancy Colorectal cancer again is similar to prostate cancer, at 15 percent at Baptist Cancer Institute is similar to being low at 5 percent compared to 9 percent in both Florida at 15 percent and the U.S. data at 14 percent. Florida and the United States. If one looks at prostate cancer, the third most common Tabl e 2 Primary Sites : Baptist Medical Center South (2012) Total % Male Female Breast 148 26% 0 148 Lung 65 11% 29 36 Colorectal 49 9% 18 31 Thyroid 46 9% 17 29 Urinary Bladder 41 7% 34 7 Kidney 35 6% 19 16 UGI 25 4% 13 12 Lymph Nodes 24 4% 12 12 Blood & Bone Marrow 22 4% 15 7 Female Genital 19 3% 0 19 Melanoma 18 3% 12 6 Pancreas 16 3% 10 6 Other Sites 15 3% 10 5 Prostate 14 2% 14 0 Head & Neck 13 2% 9 4 Unknown Primary 9 2% 2 7 Brain & CNS 8 2% 0 8 567 100% 214 353 Total 11 Baptist Cancer Institute 2013 Annual Report Site Tabl e 3 Comparison Data with Florida and United States Organ Site Baptist Cancer Institute Florida United States Breast 27% 13% 14% Lung 15% 15% 14% Prostate 9% 15% 15% Female Genital 7% 3% 5% Colorectal 5% 9% 9% Figu res for F l orida a nd U.S. a re e sti m ate s from Ca n cer Fac t s a n d Fi g u res 2 01 2 Baptist Cancer Institute 2013 Annual Report 12 These variations in data certainly represent referral Tumor Registry. In 2012, at least 10 percent of all patterns as well as expertise in programs located at the analytic cases were reviewed on a prospective basis Baptist Cancer Institute. For example, breast cancer by physician volunteering to ensure the accuracy of is represented in a high proportion because of the data. Other aspects of the data, including timeliness of preeminence of the Hill Breast screening program. data input into the Tumor Registry, are also reviewed. As well as the surgical expertise and radiation In 2012, the number of cases seen was essentially preeminence with technology, such as the IntraBeam , similar to that seen in 2011 (1625 vs. 1624). This still intraoperative treatment program. Likewise, the region represents a decline of cases compared to the peak wide digital breast cancer imaging program, housed at of 1,779 seen in 2009. (Figure 1) Currently, the Tumor Baptist Jacksonville, serves all the catchment areas of Registry includes over 28,000 cases seen and accrued this region. Expertise in medical oncology, as well as since 1990. ® research programs in both early and late breast cancer also bring a large number of referrals. The increased number of female genital malignancies is almost certainly accounted primarily by the gynecologic malignancy preeminence of the surgery group which operates primarily at Baptist Jacksonville. In 2012, the cancer clinical research programs included active participation in Eastern Cooperative Oncology Group (ECOG), Radiation Therapy Oncology Group (RTOG), and the Alliance group which represents the old Mayo Clinic Cancer Consortium. Likewise, cutting edge pharmaceutical industry sponsored As required by the American College of Surgeons, studies continue. In all, a total of 42 patients were one prospective as well as one retrospective study of accrued in 2012 with approximately 30 percent cancer disease sites, respectively, anal and chronic participating in NCI group studies and 70 percent in myelocytic leukemia are reviewed in the 2013 Annual the pharmaceutical industry studies. Report to assess the quality of data provided by the • M ajor conferences for oncology nurses • P revention and community education programs • C ontinued participation in the American Cancer Society and Leukemia and Lymphoma Society Committees • Special oncology nursing programs for community support of education in breast and lung cancer • Smoking cessation assistance programs for the • C ontinued participation of indigent programs, including the highly successful We Care program • C ontinued expansion of a hospital-based chemotherapy infusion unit • O n-site involvement of hospice and palliative care programs for optimum support for both the cancer patient and family • C ontinued expansion of the Genetic Risk Assessment Screening program, now focusing on breast cancer, community as well as employees of Baptist Health but also includes melanoma and colon cancers • C utting-edge prostate cancer treatment programs, • C ontinued active participation in the oncology including seed implants and the state-of-the-art training program for the medical oncology fellows da Vinci Robotic Surgery unit from the University of Florida Jacksonville and • C ontinued expansion of the stereotactic radiosurgery radiation program with a marked increase in the number of body sites being treated • C ontinued expansion of the limited breast radiation program using the Mammosite® technique • Continued expansion of the digital breast cancerscreening program with movement to centralized diagnostic studies at the Baptist Cancer Institute • Participation in in-patient quality improvement programs, including infection control • Expansion of the chemotherapy and the Radiation Therapy residents at Mayo Clinic Jacksonville • C ontinued expansion and utilization of the comprehensive breast health program with nurse coordinator at Baptist Jacksonville, Baptist South and Baptist Beaches • R apid expansion of the Neuro-oncology program, with continued expansion of the radiosurgery program, as well as increased sophistication of the Neurosurgery suites and continued expansion of Neuro-oncology clinical research studies radiopharmaceutical embolization programs for treatment of liver malignancies As Cancer Committee Chairman, I can state that despite continued troublesome economic times in Northeast Florida in the year 2012 the Cancer program at Baptist Hospital Systems has continued to expand compared to 2011. This collaboration has brought the Baptist Cancer Institute to its preeminent status which has maintained over time. In 2014, as Chairman, I look forward to seeing the continued expansion of our patient care, cancer research, cancer prevention, and education programs for physicians and public throughout Northeast Florida and Southeast Georgia. Exciting developments in the program hopefully will come forth from the possible alliance of Baptist Health with the Flagler Hospital System in St. Augustine, Florida and the Southeast Georgia Hospital System in Brunswick, Georgia. 13 Baptist Cancer Institute 2013 Annual Report Other Baptist cancer activities include: Baptist Cancer Institute 2013 Annual Report 14 Breast Cancer The number of breast cancer cases which are accrued A breast survivorship program with nutrition, physical to the Baptist Hospital Tumor Registry at Baptist therapy and psychosocial support has continued to Jacksonville consistently exceeds the state of Florida grow and enhance the overall experience in patients and national average. In 2012, there were a total of 440 seen at the Hill Breast Center. Cutting-edge surgery cases entered into the tumor registry representing 27 programs with intraoperative radiation began in the percent of all cases exceeding the national and state fall of 2012. Limited breast radiation with IntraBeam® of Florida average of 13 percent. Similar to previous for intraoperative breast radiation has expanded. years and similar to the national average, the majority Cutting-edge research programs both in the adjuvant of these cases are early stage breast cancer. (Figure 3) and the more advanced metastatic setting are offered Seventy-nine cases or 18 percent were DCIS, 194 cases at the Baptist Cancer Institute, through both medical (44 percent) were Stage I and 105 or 26 percent were oncology groups with cooperative group studies as well Stage II. These early stage breast cancers represent 88 as pharmaceutical sponsored and the Baptist radiation percent of all breast cancers seen and we would expect therapy through the RTOG research group. Other assets all but a few of these women would ultimately be cured for optimizing the care of breast health patients at the of their breast cancer. Stage III was 35 or 8 percent in Baptist Cancer Institute through the Hill Breast Center which many of the patients would ultimately die of their program include genetic risk assessment led by Melinda breast cancer. Stage IV was 23 patients or 4 percent and Fawbush, MSN, ARNP which assists patients and their we would expect all of the patients to ultimately die of family in making decisions for both the type of surgery their breast cancer. (Table 3) Out of these 440 cases only and other long-term preventive programs if they are four or less than one percent is classified as unknown known to have increased genetic risks. Psychosocial stage attesting to the tenacity of our Tumor Registry in support is provided by George Royal, PhD and an adequately staging the patients. increasing involvement in breast survivorship services Breast cancer consistently represents a very high percentage of the cases seen at the Baptist Cancer Institute compared to the U.S. average. This speaks to the effective network in which primary care physicians work with our digital mammogram screening program include nutrition, physical therapy, and lymphedema treatment. All of these services continue to enhance the breast health program and increase Baptist Cancer Institute’s share of breast care patients within Northeast Florida and Southeast Georgia. to diagnose patients at an early stage and move them Figure 4 shows the number of cases of ductal carcinoma into the organized breast cancer program and through in situ (DCIS) seen at Baptist Cancer Institute since the the multi-disciplinary Hill Breast Clinic. In 2012, the establishment of the Tumor Registry in 1990. Seventy- breast health program spent its second year in the Hill nine cases were seen in both 2011 and 2012. All of Breast Center at the Baptist Outpatient Center. Two these cases of ductal carcinoma in situ will be cured with nurse navigators assisted patients and physicians to local therapy and represent a success of the wide use of optimized patient convenience as well as patient care. screening digital mammograms within our system. Fi gure 3 Baptist Cancer Institute Breast Cancer Staging: 2012 250 194 200 150 105 79 100 0 1 2 4 Unknown 3 Baptist Cancer Institute 2013 Annual Report 0 4 35 15 50 23 No. of Pa t ie n t s 300 S ta g e Fi gure 4 Baptist Cancer Institute Breast Cancer-DCIS Accrual 79 79 2011 2012 55 55 50 23 1992 1993 30 17 20 25 30 29 40 34 39 40 43 50 10 60 61 56 60 2010 68 71 70 8 N umber o f Pa t ient s 80 80 81 85 90 0 1990 1991 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Baptist Cancer Institute saw 238 patients with lung cancer no accepted screening program for at least the patients in 2012. As in past years, the patients who were accrued seen in 2012. Recently, the role of low-dose screening CT to in our Tumor Registry were predominantly advanced scans has been reaffirmed at the national level, but is not cases. Unfortunately, 83 cases were Stage IV representing widely accepted since the number of false negatives and 35 percent of all lung cancer seen. (Figure 5) Forty or unnecessary biopsies is a troublesome handicap for its 17 percent were Stage III, who have approximately a widespread use. One bright spot in lung cancer at Baptist 20 percent chance of being cured. Twenty four patients Hospital is the multi-disciplinary lung cancer program were Stage II in which the cure rate is approximately 35 led by Bridget Rossi, RN, MSN, OCN, nurse navigator. percent and 89 or 37 percent were Stage I in which over Through her efforts, a foundation has been established half the patients are cured with local therapy (Figure to assist needy patients in all aspects of their care from 5). The proportion of patients with lung cancer seen at diagnosis to end of life. The role of the stereotactic Baptist Jacksonville is 15 percent, which is similar to the radiosurgery program at Baptist Cancer Institute has 14 percent seen nationally. This percentage of patients, continued to expand for selected patienta with Stage I as well as total numbers, represented a rise from the particularly who are frail and medically inoperable. previous years of 186 patients, which was 11 percent Research areas within the Baptist Cancer Institute include of the cancer seen last year. Similar to statistics both in the continued participation in a cooperative group Florida and the United States, the majority of patients adjuvant non-small cell lung cancer study, as well as with lung cancer are Stage III and IV, which are poorly innovative targeted therapies for metastatic and recurrent curable. This presentation in advanced stage represents non-small cell lung cancer. Fi gu re 5 Baptist Cancer Institute Lung Cancer Staging: 2012 83 88 100 80 40 60 24 40 3 20 0 N o. of Pati ents Baptist Cancer Institute 2013 Annual Report 16 Lung Cancer 0 0 1 2 3 S ta ge 4 Unknown Prostate Cancer staging workup. The Baptist Cancer Institute continues the 155 from the 189 cases registered in 2011. This represents prostate screening program which has been sponsored a dramatic drop from 2009 and 2008 when over 300 by both Baptist Cancer Institute and the NFL Jacksonville cases were assessed each year. This drop in prostate Jaguars for many years. The prostate cancer prevention cancer accrual represents a clear cut change in referral trial was closed in 2011 and unfortunately found no benefit patterns in the community where many patients are now to the use of antioxidants either in the form of Selenium being both biopsied and referred to outside treatment or vitamins in decreasing the incidence of prostate cancer. facilities. However, as in previous years, the vast majority of Radiation treatment at Baptist Cancer Institute includes patients are either Stage I (42 patients) which represented the state-of-the-art IMRT Radiation Therapy, or seed 27 percent of the patients seen or Stage II (97patients) implants, and urologic surgeons have the daVinci Robotic which represented 63 percent of patients. (Figure 6) Thus Surgery Program. Patients entered on an innovated 90 percent of patients were either Stage I or Stage II in immunotherapy program with the use of Ipilimumab for which the vast majority will be cured with either surgery advanced castrate resistant prostate cancer continue to or some form of radiation treatment. Only eight patients be followed in 2012 and 2013. The use of innovative new or 5 percent and four patients or 3 percent were Stage III treatments for patients previously considered refractory and Stage IV, respectively. Four patients or 3 percent were to hormone treatment has improved with two new drugs unknown stage that again represents a success for our being approved by the FDA for castrate resistant prostate Tumor Registry which accurately staged all but 3 percent cancer patients seen at Baptist Cancer Institute. of the patients. Those patients generally were cases who were referred outside our institute prior to completing 97 Fi gure 6 Baptist Cancer Institute Prostate Cancer Staging: 2012 80 42 60 40 0 1 2 3 S ta g e 4 0 4 8 20 0 No. of Pati ents 100 4 Unknown 17 Baptist Cancer Institute 2013 Annual Report In 2012, the number of prostate cancer cases dropped to In 2012, the gynecologic cancer program at Baptist to properly stage. This high percentage of patients in Cancer Center Jacksonville continued to be active in early stage represents a success in American cancer terms of numbers of patients with 116 patients seen management with a high utilization by American women this calendar year. As illustrated in Figure 7, 74 percent of standard guidelines for pelvic exam and Pap smear. or 63 patients were Stage I and II which in general is The percentage of female genital cancer seen at Baptist felt to be readily curable by surgery or surgery plus Cancer Institute (7 percent) reflects favorably with the radiation. Only 26 percent of patients were Stage III 5 percent average reported in United States SEER data. and IV and 9 or 8 percent had inadequate information Fi gu re 7 Baptist Cancer Institute Gynecological Cancer Staging: 2012 54% 60 50 40 10 8% 9% 20 9% 17% 30 4 Unknown 3% P ercent Baptist Cancer Institute 2013 Annual Report 18 Female Genital Track Cancer 0 0 1 2 3 S ta ge Colorectal Colorectal cancer represented 5 percent of all cancer 89 cases of patients diagnosed with colorectal cancer. cases seen at Baptist Cancer Institute and accrued into This mirrors the same total access in 2011 of colorectal our Registry compares unfavorably with the 9 percent cases seen at Baptist Jacksonville. Most of those rate for the state of Florida and the 9 percent rate for patients represented late stage either Stage III, which the United States. This low percentage of colorectal is regional diseases accounting for 26 patients or 30 patients seen at Baptist Cancer Institute almost certainly percent, and Stage IV which was 23 patients or 26 represents referral outside the system as well as percent. Overall, these Stages II-IV represent a total of performing biopsies and colonoscopy in freestanding 83 percent of the patients being in later stages with an ambulatory surgical centers. Reversing this trend by expectation of around 50 percent of those patients will primary care education and perhaps upgrading facilities be cured (Figure 8). Unfortunately, the 28 patients or 26 and improving access to Baptist facilities should be a percent of patients who were Stage IV most of whom top priority. A wide variety of research studies including will die within five years. A bright spot is that only one innovative metastatic treatment protocols through patient was unknown stage, who most probably left the the pharmaceutical studies as well as state-of-the-art institution prior to completing staging and having his radiation for rectal cancer are available at both Baptist treatment elsewhere. Jacksonville and Baptist South. 30% Fi gure 8 Baptist Cancer Institute Colorectal Cancer Staging: 2012 26% 26% 16% 20 1% 10 0% Perc ent 30 0 0 1 2 3 S ta g e 4 Unknown 19 Baptist Cancer Institute 2013 Annual Report In 2012, Baptist Cancer Institute tumor registry assessed Tumor Review: Anal Cancer at Baptist Cancer Institute Mark Augspurger, MD, Radiation Oncologist Each year approximately 2,000 cases of anal cancer which is a relatively rare malignancy will be seen in the United States. Because of its location proper treatment which will result in retention of bowel continuity is important. Treatment approaches have evolved over the last three decades. In the 70’s and early 80’s, the primary therapy was an abdominalperineal resection which resulted in loss of bowel continuity and a permanent colostomy. Treatment has now evolved to the point that most patients are treated upfront with chemoradiation followed by a biopsy for residual tumor and the vast majority will remain continent and cured of their malignancy. Baptist Cancer Institute 2013 Annual Report As stated, anal cancer is rare and is the cause of only when more advanced disease is found CT scans of the chest and when clinically appropriate bone scans. 1 percent of large bowel cancers. Most are squamous Staging cell cancers with other histologies being rarely seen. Anal cancer is usually seen in people over the age of Staging is based on an AJCC system that includes 60 and is slightly more common in men than in women. classification by T stage, by size and invasion, and N In terms of etiology, the human papilloma virus (HPV) stage by nodal base involvement, sub-classified by has been strongly linked to squamous cell carcinoma anatomic region. Metastases are usually present or of the anus particularly in younger individuals. absent. A T1 is any tumor less than or equal to 2cm. Analysis for HPV within the tumor cells currently finds T2 is greater than 2cm but less than 5cm. T3 is greater approximately 30 percent of patients being positive on than 5cm in greatest diameter. T4 is any tumor that immunofluourescent stains. Chronic inflammation such invades adjacent organs such as the vagina, bladder, as fistulas have also been implicated as risk factors. and urethra or stuck to the pelvic walls. Regional nodes are N1, perirectal lymph node involvement, N2, Most cancers arise from the anal canal which the metastases to unilateral internal ileac or inguinal nodes American Joint Commission on Cancer defines as and N3 metastases to perirectal and inguinal nodes or the region from the anal rectal ring to the anal verge. bilateral internal iliac or bilateral inguinal lymph nodes. They can generally be divided into those that are As stated, M is any distant metastases. In terms of final keratinizing and those that are not which are much stage, Stage I is a T1N0M0 which is cured in greater less common. There is no difference between the two than 95 percent of patients. Stage II is either a T2 or T3 histologies in overall clinical outcome. and is cured in approximately 90 percent of patients. T3A is a T1 to T3 with N1 disease or a T4N0 in which Signs, Symptoms and Diagnosis approximately 70 percent of patients will be cured. T3B is a T4N1 or any T with N2 to N3 disease in which Most tumors present with bleeding and diagnosis the survival rate drops to 50 percent or less. Stage IV can be delayed since many patients regards these which is any metastatic site, long term survival is only symptoms as representing hemorrhoids or anal fistulas. around 5 to 10 percent at five years. Regional spread is commonly in inguinal lymph nodes and less common spread distally to sites such as the liver, lung, and bone. Other areas of regional involvement include pelvic nodes, iliac nodes and retroperitoneal lymph nodes. Clinical presenting signs and symptoms besides bleeding include pain, change in bowel movements and palpable lymph nodes. Treatment For anal cancers that are Stage I, surgery alone with wide local excision and careful follow up is usually sufficient. Those tumors that reoccur locally should be treated preferably with concurrent chemoradiation and Diagnosis is usually made by digital exam with again excellent long term survival expected. For Stages palpation and biopsy. Other testing should include II through IIIB, current therapy is very standardized. anoscopy and rectal ultrasound. Further extent of the The standard treatment is radiotherapy combined disease should include either a CT scan of the pelvis with 5FU and mitomycin. Radiation therapy dosage is and abdomen or MRI of the pelvis and abdomen and usually around 45Gy with chemotherapy being given during the six week time period of radiation therapy. 21 Baptist Cancer Institute 2013 Annual Report Epidemiology Table 1 Cases by Gender (2003 - 2012) 5 5 6 Site 4 4 4 4 5 4 2 2 3 2 1 N o . of Pa ti ents 1 0 Baptist Cancer Institute 2013 Annual Report Fi gure 1 Baptist Cancer Institute Anal Cases by Year 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Male Female Anus & Anal Canal 31 13 18 Total Cases 31 13 18 2012 Year Ta ble 2 Site by AJCC Stage Tabulation 22 Site Total Stg 0 Stg I Stg II Stg III Stg IV UNK Anus & Anal Canal 31 3 4 11 8 3 2 Overall Totals 31 3 4 11 8 3 2 After radiation is complete, six weeks later complete Despite our small population size the survival of our restaging and biopsy are done. If there is residual patients was very similar to U.S. statistics. In Figure 2, disease, an additional boost of radiation therapy as you can see, the five-year survival for Stage 0, in usually combined with further therapy such as 5FU and situ disease, and Stage I is greater than or equal to 95 cisplatin is given. For patients whose primary tumors percent. Stage II is approximately 85 percent and even were larger such as T3 or T4 approximately 50 percent Stage III which is regional disease remains good at 58 will need an abdominal peritoneal resection with percent. Stage IV is somewhat high at 20 percent this permanent colostomy. Fortunately, for most patients is most likely due to the fact that only three patients the malignancy is localized for many years and overall were Stage IV. In terms of treatment, Table 2, survival, except for those who present as Stage IIIb and there is a small problem with our data. As stated, IV, is good. At Baptist Health, the Tumor Registry at most patients with Stage 0 or I would be treated with Baptist Cancer Institute accumulated 31 cases of anal surgery alone and that figure of five is compatible with cancer between the years of 2003 and 2012 (Figure 1). the national standards. However, Stages II through IIIb Of those patients, 13 were male and 18 were female would usually be treated with either chemotherapy (Table 1) which is not consistent with national average plus radiation or all three forms of therapy, surgery, but probably represents our small number of patients. radiation and chemotherapy. Our Tumor Registry has In terms of stage, (Table 2) three were in situ disease, only 15 patients treated with these modalities with four were Stage I, 11 Stage II, eight Stage III, three 12 being treated with chemotherapy plus radiation Stage IV and two were stage unknown. This is similar and three being treated with surgery, radiation and to national statistics where most patients are Stage I chemotherapy. This is somewhat problematic since and II. In terms of ethnic status of our 31 patients seen we have within our staging 11 patients in Stage II and at Baptist Cancer Institute, 24 were Caucasian, five eight patients in Stage III for a total of 19 patients who were African American, one was Asian and one was should have been treated with either chemoradiation ethnic status undetermined. or chemoradiation followed by surgery. Stage IV for lost to follow up after the original diagnostic biopsy. would be treated with chemotherapy alone or perhaps Thus in summary, information on anal cancer although palliative radiation plus chemotherapy and this is small number of cases generally represent that seen consistent with our two patients being treated with elsewhere where most patients are early stage and their chemotherapy alone. The most concerning data is survival is excellent. The male-to-female ratio most seven patients are listed as receiving no therapy which certainly represents the small patient sample and there would be very unlikely and most probably represents is no possibility that mistakes in gender were made patients being referred elsewhere for their therapy for through the Tumor Registry. On the other hand, the which we have not been able to capture the treatment number of patients, seven out of 31, listed as having data. This data will be discussed further under our no therapy are problematic in the sense that they have article for quality assurance but to briefly summarize been lost to follow up at least for treatment status and most of these patients listed as receiving no therapy, thus survival status may be somewhat clouded as well. seven out of 31 or 23 percent probably represent being This is discussed under the quality assurance article. Figu re 2 Survival Rates Over Five Years (Cases Diagnosed 2003 - 2006) 100 95 90 85 80 Cu mu lati ve Su r vi val Rates 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 0.0 1.0 2.0 3.0 4.0 5.0 Year s from Di ag nos i s Stag e 0 Stag e I Stag e II Stag e III Stag e IV 23 Baptist Cancer Institute 2013 Annual Report which Baptist Cancer Institute recorded three patients Tumor Review: Chronic Myelocytic Leukemia at Baptist Cancer Institute Troy Guthrie, MD, Medical Director, Baptist Cancer Institute Chronic Myelocytic Leukemia is a clonal chronic myeloproliferative leukemia associated with a unique chromosomal abnormality named the Philadelphia (Ph) chromosome. The Philadelphia chromosome is a balanced translocation from chromosome 9 to chromosome 22. This unmasks two genes, the ABL, which is on chromosome 9, and the BCR, which is on chromosome 22. This chromosome abnormality produces a fusion protein BCR-ABL which is thought responsible for the emergence of the leukemia clone and uncontrolled proliferation. Chronic myelocytic leukemia represents approximately 15 to 20 percent of all leukemia diagnosed. In 2012, it was estimated that approximately 4,500 cases would be diagnosed within the United States. The average age at diagnosis is between 40-60 Baptist Cancer Institute 2013 Annual Report percent of cases. The BCR-ABL protein can be detected cases to female cases. In terms of etiology, the only by two techniques, the polymerase chain reaction known risk factor is exposure to ionizing radiation (PCR) or the fluorescent in situ hybridization (FISH) and which can either be therapeutic or environmental such should be likewise present in 98 percent of the cases. as nuclear power reactor accidents or those exposed Currently, those cases approximately 2 to 3 percent that in Japan to the atomic bombs. There are no linked are “Philadelphia chromosome negative” are usually genetic factors nor any other environmental exposures. managed as non CML cases. Presentation Treatment Typically, CML has a biphasic course where in modern Chronic myelocytic leukemia in the last ten years times, 90 percent of patients present in what is called has evolved into the most successfully treated a chronic phase characterized primarily by mature hematologic malignancy occurring in man. The unique myeloid precursors in both the peripheral blood and Philadelphia chromosome abnormality which is the bone marrow and about ten percent in what is called driving force for CML is down regulated by multiple a blastic phase where they appear to be in an acute new drugs which are called tyrosine kinase inhibitors. leukemic stage either myeloid or lymphoid. In recent These drugs include imatinib (Gleevec), dasatinib years, approximately half of all patients are found (Sprycel) and others. In the chronic phase as frontline accidentally on review of blood counts and about half therapy virtually 100 percent of patients will achieve of the patients present with symptoms such as fatigue, a complete hematologic remission with normalization weight loss, or left upper abdominal pain or fullness of blood and bone marrow. Depending on the related to splenomegaly. More uncommonly, people drug used, approximately 70 to 80 percent will also will present with bleeding, overt hepatosplenomegaly, achieve a cytogenetic remission with disappearance or signs and symptoms of acute leukemia. of the Philadelphia chromosome. More importantly, molecular probes, such as PCR, for the BCR-ABL fusion The diagnosis is made by examination of the protein become negative in up to 50 percent of cases peripheral blood and bone marrow with cytogenetic treated today. The appearance of either a cytogenetic and molecular analysis for the presence of the remission or molecular remission is associated with Philadelphia chromosome and its fusion protein, the a five year survival of greater than 90 percent. There BCR-ABL protein. In chronic phase, the peripheral is even some evolving evidence that patients in blood will usually have leukocytosis between 30,000 cytogenetic remission or more importantly molecular and 50,000 with the majority of the cells being mature remission for a prolonged period of time can have and less than 5 percent myeloblasts. Likewise, the bone the treating drug discontinued and about half of the marrow will be very hypercellular with the majority of patients remain undetectable as far as their chronic the cells again mature myeloid precursor. Cytogenetic myelocytic leukemia. analysis reveals the Philadelphia chromosome in 98 25 Baptist Cancer Institute 2013 Annual Report years of age. There is a slight predominance of male inhibitors. (Table 3) Eleven were assessed as having no frequently in the 1990’s through 2004, has virtually therapy which is inconceivable since modern therapy disappeared except for treatment of the most over the last years would be to treat those patients refractory patients or patients who present in blast with oral tyrosine kinase inhibitors. Thus, it is suspected crisis. Chemotherapy as a form of treatment for CML that those 11 patients were lost to follow up as far is essentially no longer used in the United States. as treatment data. As stated in the other primary Likewise, alpha interferon, which had some success in site review, anal cancer, this issue will be reviewed the late 1990’s, is no longer used. and steps taken to alleviate this problem. In terms of survival data, the SEER data does not produce survival Baptist Cancer Institute Statistics by stages since chronic myelocytic leukemia has no stage. As stated, the five year survival is close to a 100 percent which our patients achieved. The records of the Baptist Cancer Institute Tumor Registry from 2003 to 2012 were reviewed and a total In summary, chronic myelocytic leukemia is a relatively of 31 cases were identified. As can be seen in Figure 1, rare leukemia accounting for only 15 to 20 percent of the number of cases in any year was quite variable. all leukemias, which can be seen by our small number Similar to national statistics, there was a slight male of 31 this is similar to our data. There is a slight male predominance with 16 cases being male and 15 cases to female predominance which our data also showed. female. In terms of ethnicity, 20 cases were Caucasian Survival is essentially 100 percent at five years which and 11 cases were African American. (Table 1 and 2) In our patients achieved. In terms of treatment, our data looking at treatment, similar to anal cancer, the other is lacking since in the United States no patient with primary site, once again a problem with treatment is CML would go untreated and we had 11 or 33% listed identified. Only 20 were listed as being treated with as having no treatment. chemotherapy, which includes the tyrosine kinase 8 Fi gu re 1 Baptist Cancer Institute Chronic Myelocytic Leukemia Cases by Year 8 6 7 6 4 4 5 4 4 2 2 3 2 0 1 1 0 No . of Pat ients Baptist Cancer Institute 2013 Annual Report 26 Allogenic transplant, which used to be employed 0 2003 2004 2005 2006 2007 2008 Year 2009 2010 2011 2012 Tabl e 1 Cases by Gender (2003 - 2012) Site Total Male Female Blood & Bone Marrow 31 16 15 Total Cases 31 16 15 27 Site Total White Black Asian Oriental Mer India Blood & Bone Marrow 31 19 11 0 0 0 1 Overall Totals 31 19 11 0 0 0 1 Baptist Cancer Institute 2013 Annual Report Tab l e 2 Site by Race Tabulation Other Tabl e 3 Site by Treatment Tabulation Total Chemo None Surgery Radiation Surgery/ Radiation LL Others Blood & Bone Marrow 31 20 11 0 0 0 0 Overall Totals 31 20 11 0 0 0 0 Site Quality Assurance Troy H. Guthrie Jr., MD, Medical Director, Education and Research, Baptist Cancer Institute, Melissa McCarthan, RHIT, CTR; The Tumor Registry and its database are necessary for quality of care, monitoring provided within the confines of Baptist Healthcare Systems. The Baptist Cancer Institute reviews each year the accuracy and dependability of this essential service. This year, two primary sites chronic myelocytic leukemia and anal cancer were evaluated and examined as directed by the American College of Surgeons and the Commission on Cancer. The review of the 31 cases of anal canal cancer and 31 cases of chronic myelocytic leukemia resulted in an analysis of their diagnosis as well as treatment and survival over a 10 year period of 2003 through 2012. The abstracts were reviewed for accuracy and charts will be pulled for remedial data clear up as deemed necessary. The following are the results of the assessment of the 31 cases with anal canal and 31 cases of chronic myelocytic leukemia in our Tumor Registry during the above mentioned time period: Baptist Cancer Institute 2012 Annual Report • Recommendations for corrections include: periodic accuracy. There were no errors in the classification of education for the Tumor Registry concerning standard anal canal cancer and chronic myelocytic leukemia treatment of primary sites so that when a patient patients identified in terms of diagnosis. is labeled as having no therapy this error can be • T herapy of both anal cancer and chronic myelocytic corrected early. My plan is to provide a table of the leukemia had the same problems in identifying standard treatments given to common malignancies at treatment. specific stages so that the Tumor Registry can review • O f the 31 cases of anal caner, seven or 23 percent were listed as having no therapy. Likewise, 11 or 33 percent of the 31 cases of chronic myelocytic leukemia to see if our data matches the standard of care for 2013 and on. • This issue will be brought up at Cancer Committee were listed as having no therapy. Clearly, this is so that the physicians’ staff will be more cooperative considered unlikely, so charts will be pulled from the in providing information including treatment to the patient’s last listed treating physician so that hopefully Tumor Registry. an accurate treatment can ultimately be entered into • Cancer physicians again will be urged to be more the patient’s tumor registry record and provided to involved in the abstract process particularly when the the Florida Cancer Registry as updated. This will be Tumor Registry has inconsistent data with standard of one of our cancer quality improvement projects for the care or the patient appears to be lost to follow up. upcoming year. This will be a laborious task but will be necessary so that we can have accurate long term follow up on both sites. • K aplan Meyer survival curves were available and appeared to be accurate for anal canal. Demographics in terms of male and female ratio as well as ethnic status are likewise accurate. 29 Baptist Cancer Institute 2013 Annual Report • A bstracts contained adequate information to assess Clinical Research and Education In 2012, cancer research for the Baptist Cancer Institute continued to function at a high level at multiple sites including the Baptist Cancer Institute, Florida Radiation Oncology Group and Cancer Specialists of Northeast Florida. Patients could access approximately fifty to sixty research protocols for consideration for patients with diverse cancer sites including breast, lung, gastrointestinal, brain, melanoma, pancreatic, hematologic malignancies, and other less common sites. Protocols were available for patients at both Baptist Medical Center Jacksonville and Baptist Medical Center South for both local patients and referrals from outside the Jacksonville area, including southeast Georgia. Studies were available to patients from both national cooperative groups including the National Surgical Adjuvant Breast and Bowel Project (NSABP), Eastern Cooperative Oncology Group (ECOG), North Central Cancer Treatment Group (NCCTG), and Radiation Therapy Oncology Group (RTOG), as well as many studies which came through pharmaceutical companies and private research organizations (PRO). On Campus, approximately Baptist Cancer Institute 2013 Annual Report patient accrual for all participants consisted of 42 cooperative group studies and 70 percent were patients compared to the 35 patients in 2011 (Table 1). industry sponsored pharmaceutical studies. This turn Accrual throughout the campus has remained well to industry trials was forced by poor reimbursement by below 100 patients per year due to diverse reasons NCI trials. including increasing pressure on physicians to deal All studies done on campus, either NC-sponsored or pharmaceutical-sponsored were reviewed by the Baptist Medical Institutional Review Board (IRB) for appropriateness of research, conflict of interest and protection of human rights. All studies were then described in language understandable to the public in with increasing patient volume, increasing complexity of insurance and third party payment, as well as reluctance of patients to participate in studies that may cause economic pressure. Hopefully, patient accrual will increase in 2013 to above 50 patients close to years past. an informed consent and also published on the Baptist Baptist Cancer Institute continues to be an active Cancer Institute website. Phases of studies including community cancer education program offering CME phase I, phase II and phase III were available in 2012. sessions at the multi-specialty breast cancer conference, In 2012, studies followed at the Baptist Cancer Institute had led to FDA approval recently of Ipilimumab for the treatment of metastatic melanoma, Aldo-herceptin for the treatment of HER2+ breast cancer and afatinib for the treatment of EGFR mutation positive non-small cell lung cancer. In addition to treatment protocols, a number of registry studies were done that include SystHERs in HER2+ breast cancer that is metastatic, treatment approaches in metastatic melanoma, as well as studies in chronic myelocytic leukemia and paroxysmal nocturnal hemoglobinuria. The 2012, neuro-oncology conference, lung cancer conference and tumor board. Table 2 lists the subjects of the annual tumor board for 2013. Table 3 lists the active participants in the cooperative groups at Baptist Medical Center, as well as those involved in the research programs of the NSABP and RTOG study groups. In summary, the Baptist cancer program continues to offer exciting clinical projects through both cooperative group mechanisms as well as pharmaceutical studies. A great deal of enthusiasm on the campus exists for continuing to increase patient accrual and increasing the relevance of clinical trials for every day treatment. 31 Baptist Cancer Institute 2013 Annual Report 30 percent of the studies were through NCI-sponsored Baptist Cancer Institute 2013 Annual Report 32 Ta ble 1 Clinical Research BCI: 2009 – 2012 Year # of Patients 2009 90 2010 65 2011 35 2012 42 Ta ble 2 Tumor Board: 2013 Gallbladder Cancer 1/713 John Crump, MD Lung Cancer Staging 2/21/13 Harry D’Agastino, Jr., MD Two Interesting Head and Neck 4/11/13 Troy Guthrie, MD Accuboost Lumpectomy 4/18/13 Michal Woolski, MD Myelodysplastic Syndrome 5/9/13 Troy Guthrie, MD Portal Vein Thrombosis 5/16/13 Dimitrios Agaliotis. MD Management of Uterine Cancer 5/3013 Mark Augspurger, MD Two Strange Cancer Patients 6/6/13 Troy Guthrie, MD New Options for the Management of Bone 6/13/13 Cynthia Anderson, MD What’s my “cell” line? 6/20/13 Paul Oberdorfer, MD Brain Metastases 8/8/13 Troy Guthrie, MD Two Interesting but Unfortunate 9/19/13 Dimitrios Agaliotis, MD From daVinci to Disruptive Innovation 9/5/13 John Murray, MD Genetic Update 2013 10/17/13 Melinda Fawbush, MSN,ARNP The Management of Prostate Cancer 12/1913 Mark Augspurger, MD Table 3 RTOG Dimitrios Agaliotis, MD, PhD – Medical Oncology Cynthia Anderson, MD – Radiation Oncology Jeff Bubis, DO – Medical Oncology Mark Augspurger, MD – Radiation Oncology Stephen Buckley, MD – Gynecologic Oncology Jessica Bahari, MD – Radiation Oncology Catherine Bush, RN, OCN, BSN – Study coordinator Abhijit V. Deshmukh, MD – Radiation Oncology Andrea Canto – Study Coordinator Kenneth Goldstein, MD – Radiation Oncology Carlos Castillo, MD – Medical Oncology Troy Guthrie, MD – Medical Oncology Roxane Green – Regulatory Coordinator Douglas W. Johnson, MD – Principal Investigator Troy Guthrie, MD – Principal Investigator, ECOG, NSABP, Mayo Trials Group Anand Kuruvilla, MD – Radiation Oncology Zhen Hou, MD, PhD – Medical Oncology Carla Malott, RN – Clinical Research Associate Douglas W. Johnson, MD – Sub-Investigator, Radiation Oncology Thomas Marsland, MD – Medical Oncology Robert A. Joyce, MD – Medical Oncology Lois Morgan, RN – Clinical Research Associate Mohammad Khan, MD – Medical Oncology Michael Olson, MD – Radiation Oncology Mathew Luke, MD – Medical Oncology Niraj Pahlajani, MD – Radiation Oncology Alan Marks, MD – Medical Oncology Shyam Paryani, MD – Radiation Oncology Joseph Mignone, MD – Medical Oncology Jan Peer, CCRP – Clinical Research Associate Yuval Naot, MD – Medical Oncology Sonya Schoeppel, MD – Radiation Oncology Jeanine Richmond, RN, BSN, OCN, - Study Coordinator Neenad Sha, MD – Radiation Oncology Matthew Robertson, MD - Gynecologic Oncology Dwelvin Simmons, MD – Radiation Oncology Mila Shteyn, MA - Study Coordinator Robert Still, MD – Surgeon Unni Thomas, MD – Medical Oncology J. Wynn Sullivan, MD – Medical Oncology Maria Valente – Medical Oncology Linda Sylvester, MD – Medical Oncology Mitchell Terk, MD – Radiation Oncology Carlos Vargas, MD – Radiation Oncology Prevention (NSABP and SWOG) Andrea Canto – STAR Program Coordinator John Wells, MD – Radiation Oncology Larry Wilf, MD – Nuclear Medicine Radiologist Michal Wolski, MD – Radiation Oncology Troy Guthrie, MD – Principal Investigator Cancer Risk Assessment and Genetics Melinda Fawbush, ARNP, MSN Troy Guthrie, MD – Principal Investigator 33 Baptist Cancer Institute 2013 Annual Report Cooperative Group Trials (BCI) 1235 San Marco Boulevard Jacksonville, Florida 32207 904.202.2273 baptistjax.com