CANCER PROGRAM - Orlando Health

CANCER PROGRAM
Annual Report 2010
With statistical data from 2009
Orlando Health Cancer Program:
Orlando Regional Medical Center
Arnold Palmer Hospital for Children
Winnie Palmer Hospital for Women & Babies
M. D. Anderson Cancer Center Orlando
Dr. P. Phillips Hospital

Table of Contents
Section One......................................................................................... 3
Cancer Program Overview
Section Two......................................................................................... 4
Chairman’s Report
Section Three.................................................................................... 5
Physician Liaison Report
Section Four........................................................................................ 6
Oncology Policy and Planning Committee
Section Five......................................................................................... 8
“Strength and Dedication” - A survival story
Section Six............................................................................................ 9
Clinical Research Report Goals and Accomplishments
Section Seven................................................................................. 10
Community Outreach Report
Section Eight................................................................................... 12
Cancer Database Report
Section Nine.................................................................................... 28
Patient Care Evaluation Study
Section Ten........................................................................................ 47
Glossary
2

Cancer Program Overview
The Orlando Health Cancer Program is comprised of the following
facilities: Orlando Regional Medical Center, M. D. Anderson Cancer
Center Orlando, Dr. P. Phillips Hospital, Arnold Palmer Hospital for
Children and Winnie Palmer Hospital for Women & Babies.
The Cancer Program is approved by the American College of Surgeons
Commission on Cancer (ACoS CoC) as a teaching hospital cancer program.
The program standards set forth by the CoC ensure that we have people, resources
and expertise to deliver high-quality patient care from diagnosis through treatment and
continuing through the end of life.
Inpatient and outpatient services are provided with a full complement of diagnostic and treatment services. Other
essential support services available to our patients and their families include: genetic counseling, cancer screening and prevention
services, a learning resource center, support groups, pain management, nutrition services, rehabilitation services, mind/body/
medicine program, child life program, pet therapy and spiritual care.
Basic and translational research is being conducted at M. D. Anderson – Orlando’s Cancer Research Institute. Patients also have the
option to participate in clinical trials representing prevention, treatment, quality of life assessment and epidemiology projects.
This annual report offers us the opportunity to share with you the accomplishments of the multidisciplinary professional teams
involved, directly and indirectly, in the care of our patients.
We are committed to “using every available resource to defeat cancer.”
3

Chairman’s Report
D. Wayne Jenkins, MD
Chairman
Oncology Policy and Planning Committee
Although the Cancer Program at Orlando Health continues to offer its patients
state-of-the-art technology and the most up-to-date treatment in cancer care, this
would not be possible without devoted caregivers. Patients and families find a
continuum of care from the multidisciplinary diagnostic and treatment programs
to genetic counseling, palliative care, nutrition services, patient/family counseling,
rehabilitative and other supportive services.
This 2010 Annual Report outlines the activities and accomplishments of our
cancer program for the year and provides statistical information about patients’
treatment at our facilities during 2009. This past year was marked by these notable
accomplishments:
• Opened a breast survivorship clinic
• Expanded the Pediatric Hematology/Oncology Unit
• Expanded and relocated the Pediatric Hematology/Oncology Outpatient clinic
• Developed a pediatric multidisciplinary, comprehensive Neuro-Oncology clinic
• Implemented a Web-based brain tumor support group (patients and families can
attend the support group or participate through Web conferencing)
• Expanded and relocated the Head and Neck clinic to include a Dental
Oncology clinic
• Enrolled more than 8 percent of our analytic patients in clinical trials
• Initiated the development of chemotherapy order sets for computerized physician
order entry (CPOE) for inpatient and outpatient areas
• Expanded community outreach through partnerships with community agencies
to raise cancer awareness, encourage prevention and promote screening activities
• Hosted a Head and Neck Symposium for patients and families
M. D. Anderson – Orlando’s Cancer Research Institute hosted its second annual
Research Symposium in collaboration with the Burnham Institute and the University
of Central Florida. There were more than 100 scientists, physicians, clinicians and
other medical professionals in attendance.
From the strategic initiatives of the Orlando Health Board of Directors, executives
and medical staff leadership, to the dedication of our Oncology Policy and Planning
Committee who monitor cancer care and outcomes, to the physicians, clinicians,
ancillary and other support staff who deliver the care and services to the patients,
we have an unwavering commitment to provide the highest quality clinical care in a
caring, compassionate environment.
4

Physician Liaison
Report
For the past several years, it has been a privilege to serve M. D. Anderson Cancer
Center Orlando and Orlando Health as the Physician Liaison between the Oncology
Policy and Planning Committee (OPPC) and the American College of Surgeons
Commission on Cancer. In fact, I have lost track of the year that I first agreed to
serve in this capacity, but it must have been around 1985. This position will soon be
assumed by Luis Herrera, MD, a gifted young thoracic surgical oncologist who joined
M. D. Anderson – Orlando in 2006 when he completed his fellowship in thoracic
surgery at The University of Texas M. D. Anderson Cancer Center in Houston.
The Physician Liaison has several roles and responsibilities, the most significant
being to communicate the commission’s directives or standards to the OPPC and
the organization for which that collection of professionals serves as the cancer
committee. Every three years the commission surveys the organization’s cancer
program to be assured that it is adhering to the numerous standards that are
expected for it to continue to be an accredited program of the American College
of Surgeons. For more than 25 years, Orlando Health’s cancer program has been
accredited as a Teaching Hospital Cancer Program, the highest level of accreditation
within the varied categories set out by the commission—save for the category of
National Cancer Institute designation.
Another important role of the Physician Liaison is to serve as an “agent of
change in the community,” which means this position interacts with agencies
within the community such as the American Cancer Society, the Leukemia and
Lymphoma Society and others that are involved with cancer patients and their
families. Education is a key component of the cancer program and being engaged
with the medical and lay community in this endeavor is another major responsibility
of the Physician Liaison.
I will continue to serve on the OPPC as a representative of the M. D. Anderson – Orlando
Administration Department. I have been honored to be a part of this committee
serving as the Physician Liaison for all these years and have strong faith that Dr.
Herrera will serve the organization well as he assumes the position
of Physician Liaison.
Clarence H. Brown III, MD
President and CEO
M. D. Anderson Cancer Center Orlando
5

Oncology Policy and
Planning Committee
The Commission on Cancer requires a cancer committee provide the leadership
to plan, initiate, implement and monitor all cancer-related activities. At Orlando
Health, the Oncology Policy and Planning Committee fulfills this responsibility.
The committee develops and evaluates annual goals, promotes a multidisciplinary
approach to patient management; ensures active support services are available for
patients and families; pursues performance improvement through quality studies
that focus on quality of care, access to care and outcomes; and supervises the
Cancer Database.
The membership of the Oncology and Planning Committee for 2009 included
physician and non-physician members:
Physicians
Clarence Brown, MD
Physician Liaison/Medical Oncology
Samuel Dejesus, MD
Colorectal Surgeon
Don Eslin, MD
Pediatric Hematology/Oncology
Alan Gordon, MD
GYN Oncology
Julio Hajdenberg, MD
Medical Oncology
Luis Herrera, MD
Thoracic Surgery
D. Wayne Jenkins, MD
Chair, OPPC/Radiation Oncology
Chad Kollas, MD
Pain and Symptom Management
Robert McDonald, MD
Nuclear Medicine
Gregory Pennock, MD
Director, Clinical Research
Andrew Sloman, MD
Pathology
Non-Physicians
Shalese Bennett
Child Life Specialist
Crystal Blanks
Cancer Conference Coordinator
Summer Bragg, MS, PT
Rehabilitative Services
Maria Clark, RN
Pediatric Oncology Nurse Manager
Judy Gygi, RHIA
Corporate Service Line Manager
Cancer Program
Cheryl Harrington, MS, RN, OCN
Patient Care Administrator, Oncology
Marie Mackey, RN, OCN
Nurse Manager – Outpatient
Infusion Center
Roxanne McCormac, RN
Community Outreach
Gina McNellis, RHIA, CTR
Operations Manager, Cancer Program
Anne Peach, MS, RN
COO, M. D. Anderson – Orlando
CNO, Orlando Health
Michele Pope, RN
Pediatric Research Coordinator
Mary Rogers, RN, BSN, CPON
Patient Care Administrator, Pediatrics
Ayme Smith, CHRM
Cancer Conference Coordinator
Joe Winn, LCSW
Patient and Family Counseling
6

Program Activity
Coordinators
Cancer Conferences
Crystal Blanks
Ayme Smith, CHRM
Community Outreach
Jennifer Darley, RN
Joe Winn, LCSW
Quality Improvement
Cheryl Harrington, MS, RN, OCN
Registry Quality Assurance
Gina McNellis, RHIA, CTR
7

Strength and
Dedication —
A Survival Story
Decades ago, when the United States was in the midst of an energy crisis, Francis
Underwood started to ride his bicycle. “I rode my bike to conserve energy—and for
the exercise,” he says. Cycling became more than just an every-other-day event to
Francis; he was now riding five or six times every week.
Francis served his country as a fighter pilot for the Navy in World War II. When the
war was over, Francis returned to his wife June, to whom he’s been married for more
than 65 years, and they raised two sons in Palos Verdes, California. He worked as an
aeronautical engineer for North American Aviation in Los Angeles until he retired
and moved to Florida in the early 1980s.
When he wasn’t competing in cycling events or at home working in his
garden, Francis enjoyed retirement for many years. After a routine
checkup with his primary care physician showed his prostatespecific
antigen (PSA) levels were above normal, Francis
finally broke his stride. A biopsy and clinical exam revealed
prostate cancer.
Francis was referred to M. D. Anderson Cancer Center
Orlando for further treatment. Undeterred by his
diagnosis, Francis rode into treatment just as he had his
entire life, prepared about his options. “My wife always
accuses me of gathering too much information, but
that’s just my style,” he says. “I researched the various
treatment options that were available to treat my
cancer, and decided with my urologist, Stan Sujka,
MD, on iodine seed implants.” This procedure was
successfully performed by D. Wayne Jenkins, MD, a
radiation oncologist at M. D. Anderson – Orlando,
working together with Dr. Sujka.
For his recovery, Francis credits an overall healthy
lifestyle and the treatment he received. He says that
the clinicians and other specialists at M. D. Anderson
– Orlando were “very accommodating” during his brief
stay. “They answered all the questions I had—and I ask very
pointed questions, being an engineer,” he reasons.
On August 3, 2010, Francis travelled to Louisville, Kentucky and
competed in the USA Cycling 2010 Masters Road Nationals, which
attracts more than 800 cyclists from around the country. For most everyone
else, just to finish the time trials would have been enough; but Francis finished
this race. And today, at 87 years of age, he continues to ride “whenever [he] can.”
8

Clinical Research
Report
Trudy Graves, MS, RN, CCRP
Manager, Office of Clinical Trials
Allisun Feazell, CIP, CCRP
Manager, Office of Protocol Regulations
Under the direction of Gregory Pennock, MD, our clinical trials program grew
between 2008 and 2009. In 2009 we screened more than 1,900 patients for eligibility
and enrolled 298 patients in clinical trials. We increased enrollment in pediatrics
from 13 patients in 2008 to 38 patients in 2009. For our adult patients we were able to
increase enrollment from 179 in 2008 to 260 in 2009. This participation represented
a little more than 8 percent of the analytic cases reported through the Cancer
Program. The American College of Surgeons benchmark for the Teaching Hospital
category is 6 percent.
At the end of 2009, there were 100 open accruing studies. Fifty-one trials were
Cooperative Group studies, including protocols from the Radiation Therapy
Oncology Group (RTOG), National Surgical Adjuvant Breast and Bowel Project
(NSABP), Gynecologic Oncology Group (GOG), Southwest Oncology Group
(SWOG), Community Clinical Oncology Program (CCOP) and the Children’s
Oncology Group (COG). The remaining 49 were industry- and investigatorinitiated
trials.
During 2009 the clinical and regulatory staff in the Office of Clinical Trials
increased by approximately 25 percent. In addition to the clinical trials that we have
open to treat patients for a variety of cancer types, we added a number of studies
that are designed to answer research questions about diagnosis and prognosis. To
accommodate these we opened a new section for the coordination of non-treatment
trials. Some of these trials included coordination of collecting blood samples and
data for research conducted at M. D. Anderson – Orlando’s Cancer
Research Institute.
The number of clinical trials in radiation and diagnostic imaging increased to
a volume prompting the opening of a Radiation Oncology section in 2009. To
support this new section, we hired a designated research coordinator to work
with the investigators.
In addition to the Office of Protocol Regulations, we have research offices located in
the clinic to support Medical Oncology, Radiation Oncology, Pediatric Oncology,
Breast & GYN Oncology, and Surgical Head and Neck Oncology. Both clinical
research coordinators and research regulatory team members are able to assist in
coordination of patients who are candidates for or are receiving care on clinical trials
in closer proximity to the physician investigators.
9

Community Outreach
Report
Education, prevention and early detection are vital to achieving better treatment
outcomes. The Cancer Program is committed to raising awareness about cancer,
its risk factors and treatment options through community education and outreach
programs. This commitment to our community is demonstrated by hosting
educational events at our facility as well as traveling into the community to attend
health fairs and make presentations at local workplaces, community centers and
churches. Under the direction of the clinical community oncology education
coordinator, Cancer Program physicians, nurses and ancillary staff routinely
participate in these events.
10

Highlights for 2009
Jennifer Darley, RN, OCN
Community Clinical Oncology Educator
Joe Winn, LCSW
Patient and Family Counseling
Inaugural Head and Neck Cancer Symposium — In honor of Head
and Neck Cancer Awareness week, our multidisciplinary team of physicians and
ancillary staff hosted an educational event presenting the latest research in the
prevention and treatment of Head and Neck Cancers to our patients, caregivers
and the community.
Breast Cancer Awareness — In 2009, there were 19 events targeting
breast cancer in various community settings and health fairs including events in
collaboration with the Sisters Network, a community African American women’s
breast cancer awareness group. The Cancer Program continues to help sponsor the
annual Block Walk, a neighborhood breast awareness event in underserved African
American communities. Pink Hugs is our breast cancer support group which
has been active for 16 years with regular attendance and is open to anyone in the
community with a history of breast cancer.
Prostate Awareness — Several highlights of the program included educational
classes in collaboration with LYNX bus systems and a Men’s Health Night with
the First Baptist Church of Orlando. We continued our commitment to at-risk
populations by sponsorship and participation at the annual African American
men’s summit health event.
Colon Cancer Awareness — In partnership with local physicians, two
colon cancer awareness classes and lectures were held at local Orange County
Library locations.
Skin Cancer Prevention — The Cancer Program participated in four skin
cancer awareness and sun safety education programs directed to middle and high
school students in Orange County.
Smoking Cessation Initiative — M. D. Anderson – Orlando continues to offer
free smoking cessation classes at our facility in conjunction with Florida Area Health
Education Centers.
Brain and Spine Tumor Program — Beginning in 2009, our neuro-oncology
physicians collaborated with our Patient and Family Counseling Department to
provide a live Internet broadcast program and forum open not just to our local
community, but worldwide, with presentations covering topics relevant to our
patients with brain and/or spinal tumors and their caregivers. Immediately
following the forum is a support group open to the community.
11

Cancer Database
Report
The Cancer Database plays an integral role in the Cancer Program by providing
multiple cancer data management and support services, including the collection and
analysis of cancer information on each patient diagnosed and/or treated at Orlando
Health. The Cancer Database captures a complete case summary from diagnosis
to treatment and through post-treatment. This information is maintained on an
electronic database and is used for program development, quality improvement
initiatives, identification of at-risk populations for education and screening, outcome
analysis and clinical research.
Data from the Cancer Database is submitted to the Florida Cancer Data Systems
(FCDS) and the National Cancer Data Base (NCDB). These agencies use the data to
evaluate trends in cancer incidence, diagnosis and treatment, to design and evaluate
cancer control programs and to recommend policy and research at state and
national levels.
The quality of the data maintained by the Cancer Database remains consistently
high. Peer review and FCDS quality review rates exceed the benchmark of 95
percent. For most quarters of 2009, the accuracy rate exceeded 98 percent. Physician
review also substantiates the high quality of the registry data.
The members of the Cancer Database have diverse competencies. Those who are
involved in the identification of patients with reportable diagnoses are Naquisha
Maultsby and Jennifer Markiewicz. They ensure that reportable cases are entered
into Oncolog, the Cancer Database system, so that they are available for the Certified
Tumor Registrars to abstract. There are seven full-time Certified Tumor Registrars:
Cecilia Annis, CTR; Bethaney Babin, RHIA, CTR; Joan Clark, RHIT, CTR; Mary
Ann Hopmann, RHIT, CTR; Stacye Mathis, RHIA, CTR; Gina McNellis, RHIA,
CTR, and Dorsi Rovin, CTR. The tumor registrars also attend and document cases
presented at cancer conferences.
The Cancer Database is also responsible for coordinating the cancer conferences.
Two cancer conference coordinators, Crystal Blanks and Ayme Smith, collaborate
with the physicians to schedule the patients for the conferences and coordinate with
diagnostic departments to assure the necessary films, scans and slides are available
for review and discussion at these conferences.
Multidisciplinary cancer conferences (MCC) are an integral part of the treatment
planning process. The MCC teams include physicians from Pathology, Diagnostic
Radiology, Nuclear Medicine, Surgical Oncology, Surgery, Medical Oncology and
Radiation Oncology. Cases are presented for discussion of disease progression,
treatment guidelines and treatment planning by anatomical site and/or disease.
During conferences, pertinent case information such as clinical stage, prognostic
factors and clinical guidelines are discussed. All specialties attended and met the
standard of 85 percent attendance to MCCs. This year the conference schedule
continued to grow and more site-specific conferences were added. In 2009, 97.8
percent of the patient cases discussed at these conferences were prospective.
The cancer conferences also provide educational opportunities for residents, fellows
and other clinical staff. In addition to facility-wide MCCs, site-specific MCCs are
frequently teleconferenced with our colleagues at The University of Texas
M. D. Anderson Cancer Center in Houston.
12

Cancer Database
Report (cont.)
MCC Summary 2001 2002 2003 2004 2005 2006 2007 2008 2009
Number
of Cancer
Conferences
Number of
Cases Presented
at Cancer
Conferences
99 71 127 116 149 143 238 240 285
475 351 717 642 777 843 1,634 1,783 1,815
The Cancer Database also continues to provide lifelong surveillance of our patients
through annual follow-up to monitor their health status. During 2009, Julia Grayson,
Mary Melendez and Sabrina Yambao followed more than 33,000 patients who are in
our electronic database.
Performance
Improvements
With the large number of patients presented at MCCs, the Cancer Database
continued to collaborate with the Information Technology Department for the
continual enhancement of an online scheduling system that allows physicians to
enter the cases they want to present. The system pulls this information into the
agenda and a prefilled template that can be used by the cancer registrars to document
the treatment recommendations made at the MCC for each patient. Multiple
changes, additions and modifications were added in 2009 to ensure that the ACoS
standards were met.
Consistent with the organization’s move to a paperless environment, the Cancer
Database developed a procedure for scanning agendas, MCC minutes and other
pertinent documentation for cancer conferences, and making them available online
to those who have access.
Relative to case finding, the database collaborated with the Revenue Management
Applications team to add additional ICD-9 codes to ensure the electronic capture of
all potentially reportable cancer cases.
13

Summary of 2009
Reportable Cases
Of the analytic cancer cases, 1,621 (53.7 percent) were female and 1,393 (46.2 percent)
were male (see portrait of sex graph), and less than one (0.03 percent) was other sex.
Sex - 2009 All Analytic Cases
0.03%
Male
Female
Other
46%
54%
Race is predominately white 2,490 (82.5 percent) (see portrait of race graph).
Race - 2009 All Analytic Cases
Unknown
0.6%
Other
1.1%
Other Asian
0.6%
Asian Indian
0.5%
Vietnamese
0.4%
Filipino
0.2%
Japanese
0.0%
Chinese
0.1%
American Indian
0.0%
Black
13.4%
White
82.5%
0% 22.5% 45.0% 67.5% 90.0%
Percentage
14

Top Five Sites
The five top sites treated at Orlando Health’s Cancer Program continue to be female
breast, lung, prostate, colorectal and skin melanoma. The following numbers
represent analytic cases. There were 558 cases (18.5 percent) of female breast cancer
which continues to be the primary site of greatest incidence, followed by lung cancer
(14.6 percent) with 440 cases, prostate cancer (9.4 percent) with 284 cases, colorectal
cancer (7.2 percent) with 312 cases and melanoma (5.2 percent) with 157 cases. The
remaining (45.1 percent) were all other primary sites.
Site Orlando Health Florida United States
Number Percent Number Percent Number Percent
Female
Breast
558 18.5% 12,650 12.4% 192,370 13.0%
Lung 440 14.6% 17,790 17.4% 219,440 14.8%
Prostate 284 9.4% 12,380 12.1% 192,280 12.9%
Colorectal 312 7.2% 10,420 10.2% 146,970 9.9%
Melanoma 157 5.2% 4,920 4.8% 68,720 4.6%
All Sites 3,015 102,210 1,479,350
Comparative Incidence of Top Five Sites - 2009
20.0%
18.5%
17.4%
15.0%
14.6%
14.8%
12.4%
13.0%
12.1%
12.9%
10.0%
9.4%
10.2%
9.9%
7.2%
5.0%
5.2%
4.8%
4.6%
0%
Female Breast Lung Prostate Colorectal Melanoma
Orlando Health Florida United States
15

Top Five Sites
Breast (C50.0-C50.9)
The sites have continued to remain constant over the past five years and have
maintained the same order of incidence within the five sites. The higher incidence of
breast cancer may be due to the increasing number of elderly patients, and increased
emphasis on educating women to perform monthly breast checks and obtain routine
screening mammography to identify breast cancer in its early stages when it is most
often curable. Our experience is that much of the prostate cancer is seen in urology
practices and often the first course of treatment occurs in outpatient surgery centers.
For each of the top five sites is a graph which represents the distribution of the
following items: sex, age, location and race.
Sex - 2009 Orlando Health — Breast Cancer
1.10%
Male
Female
98.90%
Age - 2009 Orlando Health — Breast Cancer
Under 20
0%
20-29
0.8%
30-39
5.0%
40-49
21.6%
50-59
26.5%
60-69
24.5%
70-79
15.0%
80-89
5.3%
90 +
0.8%
0% 7.5% 15.0% 22.5% 30.0%
Percentage
16

Top Five Sites
Breast (C50.0-C50.9)
(cont.)
Site Location - 2009 Orlando Health — Breast Cancer
0.5%
7.8%
19.8%
13.1%
6.4%
C50.0-Nipple
C50.1-Central
19.2%
C50.2-UIQ
C50.3-LIQ
6.8%
26.4%
C50.4-UOQ
C50.5-LOQ
C50.8-Overlapping
C50.9-NOS
Race - 2009 Orlando Health — Breast Cancer
Unknown
0.5%
Other
0.8%
Other Asian
1.6%
Asian Indian
0.7%
Vietnamese
0.1%
Filipino
0.7%
Chinese
0.1%
Black
15.7%
White
79.3%
0% 20.0% 40.0% 60.0% 80.0%
Percentage
17

Top Five Sites
Lung (C34.0-C34.9)
Sex - 2009 Orlando Health — Lung Cancer
0.2%
Male
Female
Other
46.3%
53.5%
Age - 2009 Orlando Health — Lung Cancer
Under 20
0.2%
20-29
0.2%
30-39
0.2%
40-49
5.4%
50-59
18.4%
60-69
31.5%
70-79
32.0%
80-89
11.3%
90 +
0.4%
0% 10.0% 20.0% 30.0% 40.0%
Percentage
18

Top Five Sites
Lung (C34.0-C34.9)
(cont.)
Site Location - 2009 Orlando Health — Lung Cancer
16.5%
1.8%
1.1%
50.6%
26.6%
3.4%
C34.0-Main Bronchus
C34.1-UL
C34.2-ML
C34.3-LL
C34.8-Overlap
C34.9-NOS
Race - 2009 Orlando Health — Lung Cancer
Unknown
0.2%
Other
0.4%
Other Asian
0.4%
Asian Indian
0.2%
Vietnamese
0.4%
Filipino
0.2%
Chinese
0.2%
Black
10.4%
White
87.2%
0% 22.5% 45.0% 67.5% 90.0%
Percentage
19

Top Five Sites
Prostate (C61.9)
Site code and sex (only male) are both at 100 percent so a graph will not be shown for
these date items.
Age - 2009 Orlando Health — Prostate Cancer
Under 20
0%
20-29
0%
30-39
0%
40-49
29.1%
50-59
20.4%
60-69
48.9%
70-79
25.3%
80-89
2.4%
90 +
0.3%
0% 12.5% 25.0% 37.5% 50.0%
Percentage
Race - 2009 Orlando Health — Prostate Cancer
Unknown
1.7%
Other
1.0%
Other Asian 0.3%
Asian Indian 0.3%
Vietnamese
0.3%
Black
19.7%
White
76.0%
0% 20.0% 40.0% 60.0% 80.0%
Percentage
20

Top Five Sites
Colorectal (C18.0-
C18.9, C19.9, C20.9)
Sex - 2009 Orlando Health — Colorectal Cancer
Male
Female
46.5%
53.5%
Age - 2009 Orlando Health — Colorectal Cancer
Under 20
0%
20-29
30-39
1.3%
1.8%
40-49
10.5%
50-59
60-69
21.6%
22.5%
70-79
25.8%
80-89
13.8%
90 +
2.3%
0% 7.5% 15.0% 22.5% 30.0%
Percentage
21

Top Five Sites
Colorectal (C18.0-
C18.9, C19.9, C20.9)
(cont.)
Site Location - 2009 Orlando Health — Colorectal Cancer
10.1%
24.4%
3.7%
9.2%
0.9%
2.8%
5.5%
14.7%
5.1%
C18.0-Cecum
C18.1-Appendix
C18.2-Ascending
C18.3-Hepatic Flex
C18.4-Transverse
C18.5-Splenic Flex
C18.6-Descending
C18.7-Sigmoid
C18.8-Overlapping
C18.9-Colon NOS
C19.9-Rectosigmoid Junct
C20.9-Rectum
18.0%
2.8%
2.8%
Race - 2009 Orlando Health — Colorectal Cancer
Unknown
0.4%
Other
0.9%
Other Asian
0.4%
Asian Indian
0.4%
Vietnamese
0.4%
Japanese
0.4%
Black
18.4%
White
78.3%
0% 20.0% 40.0% 60.0% 80.0%
Percentage
22

Top Five Sites
Skin Melanoma
(C44.0-C44.9)
Sex - 2009 Orlando Health — Skin Melanoma
Male
Female
37.5%
62.5%
Age - 2009 Orlando Health — Skin Melanoma
10-19
1.2%
20-29
5.0%
30-39
7.6%
40-49
10.8%
50-59
19.7%
60-69
20.3%
70-79
19.7%
80-89
11.4%
90 +
3.1%
0% 7.5% 15.0% 22.5% 30.0%
Percentage
23

Top Five Sites
Skin Melanoma
(C44.0-C44.9)
(cont.)
Site Location - 2009 Orlando Health — Skin Melanoma
1.9% 1.2%
14.6%
17.9%
11.4%
C44.2-Skin ext ear
16.5%
C44.3-Skin face
C44.4-Skin scalp/neck
C44.5-Skin trunk
C44.6-Skin upper limb shoulder
C44.7-Skin lower limb/hip
C44.9-Skin, NOS
36.4%
Race - 2009 Orlando Health — Skin Melanoma
Unknown
0.6%
Other
0.6%
Black
0.6%
White
98.0%
0% 25.0% 50.0% 75.0% 100.0%
Percentage
24

Primary Site Table
It should be noted that there are 760 cases where the stage at diagnosis is unknown.
This number includes both analytic and non-analytic cases. Non-analytic cases
typically do not have a stage or it is unknown when the patient arrives at Orlando
Health because all or most of their first course of therapy was given at another
institution and they have decided to come to Orlando Health for a second opinion
or for further treatment due to recurrence or progression of disease. Also while
abstracting analytic cases, the Certified Tumor Registrars must research the chart
for the notation from the physician on the Tumor, Node, Metastasis (TNM) stage
of the patient. If it is not indicated within the record by the physician, the CTR is
not able to assign this code. This issue has been noted and the cancer committee is
aware of this issue. Starting with 2010 cases, the CTR will be able to complete a more
accurate TNM stage. The change is related to the M code. If there is no mention of
metastasis then the M stage is a “0” and the stage can be more accurately completed.
Some cancers, such as Leukemia and Multiple Myeloma do not have a specific TNM
staging system so these sites are listed as not applicable (NA) regarding staging.
25

Primary Sites of Cancer for Orlando Health Cancer Program
Primary Site Cases Sex Class of Case
Stage at Diagnosis
(includes both Analytic and Non-Analytic Cases)
Male Female Other Analytic
Non-
Analytic
0 I II III IV NA UNK
Lip, Oral Cavity, Pharynx:
Lip 12 10 2 0 8 4 1 5 1 2 0 0 3
Tongue 32 22 10 0 21 11 0 7 5 3 11 0 6
Floor of Mouth 13 12 1 0 12 1 2 1 1 2 5 0 2
Palate 5 4 1 0 4 1 0 1 0 0 4 0 0
Other Mouth 17 10 7 0 11 6 0 2 2 0 8 0 5
Parotid / Salivary Glands 16 12 4 0 10 6 0 4 0 0 4 1 7
Tonsil 24 22 2 0 22 2 0 0 3 3 16 0 2
Oropharynx 7 6 1 0 4 3 0 2 0 0 5 0 0
Nasopharynx 4 3 1 0 3 1 0 0 0 2 1 0 1
Pyriform / Hypopharynx 8 6 2 0 6 2 0 0 1 0 6 0 1
Other Oral / Pharynx 1 1 0 0 0 1 0 0 0 0 0 1 0
Digestive Organs:
Esophagus 41 33 8 0 32 9 0 2 11 11 7 0 10
Stomach 61 40 21 0 47 14 0 16 6 8 15 2 14
Small Intestine 16 9 7 0 13 3 0 2 1 2 3 6 2
Colon 220 109 111 0 144 76 2 34 40 52 38 3 51
Rectum and Rectosigmoid 92 63 29 0 73 19 0 19 19 19 16 2 17
Anus, Anal Canal 21 6 15 0 15 6 0 8 5 1 1 2 4
Liver 41 36 5 0 29 12 0 5 2 11 8 1 14
Intrahepatic Bile Ducts 7 2 5 0 2 5 0 0 0 2 0 0 5
Gallbladder 6 1 5 0 6 0 1 1 2 1 1 0 0
Other Biliary 8 5 3 0 8 0 0 0 3 1 1 0 3
Pancreas 77 39 38 0 60 17 0 2 21 3 30 7 14
Other GI Tract 3 3 0 0 1 2 0 0 0 0 0 3 0
Respiratory and Intrathoracic System:
Nasal Cavity / Middle Ear /
Access Sinus
10 4 6 0 6 4 1 0 1 0 2 4 2
Larynx 39 35 4 0 25 14 1 7 5 7 12 0 7
Lung and Bronchus 530 273 256 1 440 90 0 120 21 110 179 12 88
Trachea 1 1 0 0 1 0 0 0 0 0 0 1 0
Mesothelioma:
Mesothelioma 9 8 1 0 6 3 0 0 2 3 2 0 2
Bone, Joints and Articular Cartilage:
Bone and Joint 20 12 8 0 17 3 0 4 0 0 5 2 9
Hematopoietic Reticuloendothelial:
Multiple Myeloma 73 36 37 0 34 39 0 0 0 0 0 73 0
Lymphoid Leukemia 84 49 35 0 41 43 0 0 0 0 0 84 0
Myeloid Leukemia 53 24 29 0 34 19 0 0 0 0 0 53 0
Other Leukemia 11 5 6 0 3 8 0 0 0 0 0 11 0
Myeloproliferative Disorder 9 3 6 0 2 7 0 0 0 0 0 9 0
Myelodysplastic Syndrome 41 27 14 0 15 26 0 0 0 0 0 41 0
Other Hematopoietic 25 9 16 0 10 15 0 0 0 0 0 24 1
Skin:
Melanoma 240 144 96 0 157 83 33 85 28 2 5 1 86
Other Skin (incl
Kaposi Sarcoma)
18 7 11 0 15 3 1 6 2 1 1 2 5
Retroperitoneum and Peritoneum:
Primary Sites of Cancer for Orlando Health Cancer Program
Primary Site Cases Sex Class of Case
Stage at Diagnosis
(includes both Analytic and Non-Analytic Cases)
Male Female Other Analytic
Non-
Analytic
0 I II III IV NA UNK
Soft Tissue:
Soft Tissue (incl Heart) 43 21 22 0 31 12 0 4 5 1 3 14 16
Breast:
Breast 711 7 704 0 558 153 140 178 160 61 42 0 130
Female Genital Organs:
Vulva 22 0 22 0 11 11 11 2 3 1 0 1 4
Vagina 2 0 2 0 2 0 0 0 2 0 0 0 0
Cervix Uteri 42 0 42 0 29 13 0 19 4 3 4 3 9
Corpus Uteri 110 0 110 0 93 17 1 57 11 11 7 18
Other Female Genital NOS 5 0 5 0 4 1 0 0 1 2 0 0 2
Male Genital Organs:
Prostate 454 454 0 0 284 170 0 2 280 27 34 0 111
Testis 13 13 0 0 9 4 0 7 1 0 1 1 3
Penis 3 3 0 0 3 0 1 1 1 0 0 0 0
Urinary Tract:
Kidney 102 60 42 0 74 28 0 45 3 6 17 1 30
Renal Pelvis, Ureter 18 7 11 0 17 1 4 1 1 7 3 0 2
Bladder 85 58 27 0 46 39 29 16 8 3 10 1 18
Urethra 1 1 0 0 1 0 0 0 0 0 0 0 1
Eye, Brain and Other Parts of the Central Nervous System:
Eye and Orbit 6 2 4 0 2 4 0 2 0 0 0 4 0
Brain 101 57 44 0 80 21 0 4 0 0 0 96 1
Other Nervous System 31 14 17 0 23 8 0 0 0 0 0 30 1
Benign / Borderline
Intracranial / CNS
95 29 66 0 78 17 0 0 0 0 0 95 0
Thyroid and Other Endocrine Glands:
Thyroid 101 25 76 0 81 20 0 64 6 6 6 4 15
Other Endocrine
(incl Thymus)
58 28 30 0 50 8 0 0 0 0 0 57 1
Spleen 4 1 3 0 2 2 0 2 0 1 1 0 0
Hodgkin / Non-Hodgkin:
Hodgkin’s Disease 28 16 13 0 24 5 0 5 13 5 4 0 2
Non-Hodgkin’s Lymphoma 28 19 9 0 19 9 0 5 6 2 7 0 8
Other Lymphoma 95 55 40 0 71 24 0 13 12 28 28 0 14
Waldenstrom’s
Macroglobulinemia
2 0 2 0 0 2 0 0 0 0 0 2 0
Other / Unknown:
Other / Ill Defined Sites 2 2 0 0 0 2 0 0 0 0 0 2 0
Unknown Primary 54 26 28 0 47 7 0 0 0 0 0 53 1
Total: 4,166 1,990 2,174 1 3,015 1,151 228 768 701 429 562 718 760
Retroperitoneum 4 1 3 0 3 1 0 2 0 0 1 0 1
Peritoneum, Omentum and
Mesentary
3 0 3 0 2 1 0 0 0 0 0 2 1
26
27

Patient Care
Evaluation Study
Gina McNellis, RHIA, CTR
Operations Manager Cancer
Program Registry
The 2009 Patient Care Evaluation (PCE) is Colorectal Cancer which will be reviewed
in greater detail by Samuel Dejesus, MD, regarding treatment, prognostic indicators,
tumor markers and future trends. Since the PCE was limited to the years 2003-2007
in order to obtain five-year survival data and comparison data between Florida
and the National Cancer Data Base, this report reflects the registry data related to
colorectal cases seen in 2009.
There were 217 (7.2 percent) cases with males representing 116 (53.4 percent) cases
and females 101 (46.5 percent) cases. Following is a diagram which identifies the site
location, histology and sex for the 2009 analytic colorectal cases.
Study Group: 2009 Analytic Cases
C18.3 Hepatic flexure
11 (5.1%)
C18.4 Transverse
12 (5.5%)
C18.5 Splenic flexure
6 (2.8%)
C18.2 Ascending
32 (14.7%)
C18.8 Overlapping
6 (2.8%)
C18.6 Descending
6 (2.8%)
C18.0 Cecum
22 (10.1%)
C18.9 Colon, NOS
2 (0.9%)
C18.1 Appendix
8 (3.7%)
C19.9 Rectosigmoid
20 (9.2%)
C18.7 Sigmoid
39 (18.0%)
C20.9 Rectum
53 (24.4%)
28

Patient Care
Evaluation Study
(cont.)
Histology Total Percent
Adenocarcinoma in situ 1 0.5%
Adenocarcinoma 177 81.6%
Mucinous Adenocarcinoma 12 5.5%
Signet Ring 3 1.4%
Squamous Cell 0 0%
Adenosquamous 0 0%
Small Cell 0 0%
Undifferentiated 0 0%
Carcinoma, NOS 5 2.3%
Other 19 8.8%
Distribution by Sex
Total Percent Total Percent
Male 116 53.5% Female 101 46.5%
29

Patient Care
Evaluation Study:
Colorectal Cancer
Samuel DeJesus, MD, Gastrointestinal
Cancer Specialty Section,
M. D. Anderson Cancer Center Orlando
Mark Soliman, MD, PGY VI, Colorectal
Surgery Resident, Orlando Health
Gina McNellis, RHIA, CTR
Colorectal cancer (CRC) is the third most commonly diagnosed cancer for both men
and women in the United States. It is estimated that in 2010 there will be 142,570
new cases of colon cancer diagnosed and 39,670 cases of rectal cancer. Unfortunately,
51,370 people will die of the disease. CRC is the third leading cause of cancer-related
mortality for both men and women within the United States. The average person has
a lifetime risk of 5.12 percent of developing CRC as demonstrated in SEER Lifetime
Risk. Incidence of CRC between 1975 and 2007 for both males and females continued
to see a decline in the annual percentage change (APC). The biggest decrease was
noted during 2002-2007 where it was -3.2 percent. Mortality of CRC between 1975
and 2007 for both males and females also continued to see a decline in the APC.
The biggest decrease was 2002-2005 where it was -4.3 percent. The five-year survival
from 1998-2006 from SEER geographic areas was 65 percent. There is a 90.4 percent
survival rate for those with localized disease and 69.5 percent survival rate for
those with lymphatic spread. All the improvements in the battle against CRC have
been achieved by a combination of early detection of malignant and premalignant
lesions, aggressive surgical intervention and advances in chemotherapy and radiation
treatment. (Statistics from NCI and SEER.)
Most CRC tends to originate from a polyp that grows uninhibited leading to severe
dysplasia and subsequent malignancy. The process of a polyp progressing to cancer
can take years. Since 1969 when the first removal of a polyp was attempted via a
colonoscope at Beth Israel Hospital in New York City, colonoscopy has become one
of the primary tools to detect polyps and CRC. Almost all polyps can be removed
via colonoscopy. Colonoscopy has a low rate of complications and there are minimal
contraindications to the procedure. Although it has been established that timely
removal of adenomatous polyps can decrease the incidence of CRC, approximately
half of the population that is eligible for colonoscopy screening has not had the
screening performed. Some of the reasons for this are cost, reluctance of people
to undergo the screening, availability of experienced colonoscopists and lack of a
coordinated effort between the primary care physician and physicians performing
colonoscopies. Recognizing this gap in care, M. D. Anderson Cancer Center Orlando
partnered with the Colorectal Center of Orlando to establish a clinic within
M. D. Anderson – Orlando that facilitates referral of eligible patients for a screening
colonoscopy. Since 2004, 255 patients have undergone screening colonoscopies as
a result of this program. Even though there are other modalities, such as double
contrast enema, computer tomographic colonography, fecal occult test and flexible
sigmoidoscopy, for early detection of CRC and polyps, colonoscopy remains the
preferred method.
The current recommendation for screening colonoscopy include persons older than
50 years of age, 45 years in the African American population, and anybody with
a history of familial adenomatous polyposis, hereditary non-polyposis colorectal
cancer syndrome and history of inflammatory bowel disease. For a person with a
first-degree relative with CRC or advanced adenoma diagnosed at an age greater
than 60 it is recommended that screening begin at age 50. Likewise, for a person
with a single first-degree relative with CRC or advanced adenoma diagnosed at an
age earlier than 60 or two first-degree relatives with CRC of advance adenoma, it
is recommended that screening begin at age 40 or 10 years younger than the age of
diagnosis of the youngest affected relative.
Unfortunately, symptoms for colorectal cancer are wide and variable and can range
from nonspecific and mild to severe and life threatening. Some of the symptoms
30

Patient Care
Evaluation Study:
Colorectal Cancer
(cont.)
are bleeding with defecation, change in bowel habits, including diarrhea and
constipation, abdominal pain, cramping, weight loss, decrease in stool caliber,
fatigue, feeling of incomplete evacuation and abdominal distention with jaundice
if metastasis has occurred to the liver. Many of these symptoms will depend on the
location of the cancer (i.e., rectal cancer versus colon cancer) and the stage of the
disease. Stage of CRC is as follows: stage I, the cancer is confined to the intestinal
wall; stage II, the cancer has penetrated into or through the intestinal wall with or
without local invasion of adjacent organs; stage III, the cancer has metastasized to
regional lymph nodes; and stage IV, the cancer has spread to other distant organs,
most commonly to the liver and lung.
Once a patient is diagnosed with CRC, the process of staging and work-up will
include: physical exam, chest X-ray and computerized tomography (CT) of the
abdomen and pelvis. In many instances, a positron emission tomography (PET)
may be indicated. Also, a transrectal ultrasound may be ordered if this is impossible
because the tumor is too bulky, then pelvic magnetic resonance imaging (MRI)
may be used to delineate the extent of the invasion of the rectal cancer. Once this
information is available, a multidisciplinary approach among surgeons, medical and
radiation oncologists, pathologists and radiologists is used in order to determine the
best course of treatment or sequence of treatments for the patient.
In the last 10 years, there have been advances in minimally invasive surgery. This
has resulted in an increase in the number of complex surgical procedures being
performed laparoscopically with excellent outcomes. In 2004, a trial (the COST trial)
showed that the outcomes of laparoscopic surgery were similar to the open approach
in regard to survival, recurrence and complication rates with the benefit of less time
spent in the hospital and less discomfort for the patient. The number of laparoscopic
cases performed at Orlando Health continues to increase. More recently, roboticassisted
surgery in the field of CRC has been introduced as another tool for the
surgical treatment of CRC, but it is still in the early stages of adoption. In regard
to rectal cancer, one of the techniques increasingly used for very early, small rectal
cancers is transrectal endoscopic microsurgery (TEM) which allows resection of
lesions high in the rectum and is much less invasive than traditional surgery.
Adjuvant chemotherapy continues to be a mainstay therapy for most stage III colon
cancer (with few exceptions for stage II) and stage II and III rectal cancer. There have
been important advances in chemotherapy drugs and regimens in the last 10 years
that continue to make a significant difference in the treatment of patients with stage
IV CRC. The Orlando Health Cancer Program has directed efforts to increasing
educational programs specific to CRC and streamlining access to screening tests
to detect, prevent and/or treat CRC. These efforts include making informational
literature and educational seminars available to the public and providing ease of
access to screening colonoscopies for average and high-risk persons.
A patient with newly diagnosed CRC will undergo a multi-specialty approach
to treatment which includes consultation with surgeons, medical and radiation
oncologists. Also available are cancer conferences which maximize communication
between subspecialties to tailor treatment modalities for each patient. Participating
in these conferences are surgeons, medical and radiation oncologists, diagnostic
radiologists and pathologists, each contributing their expertise to the patient’s
treatment plan.
31

Patient Care
Evaluation Study:
Colorectal Cancer
(cont.)
Patients who are to undergo surgery have a thorough work-up to assess the spread
of the cancer. Endorectal Ultrasound (ERUS) is one test that is often performed.
It affords preoperative staging data to guide the therapy. MRI is also useful when
ERUS is not possible. Any rectal cancer that is a T3 (full thickness involvement
of the rectal wall) or N1 (spread of tumor into rectal lymph nodes) typically
undergoes preoperative chemo-radiation therapy, which greatly helps in
sphincter sparing surgery.
Surgical excision of the cancer remains the mainstay of treatment. While some CRC
cancer still requires a traditional open surgical approach, national trials (e.g., COST
trial published 2004 and 2007) and international studies (Braga et al., Br. J Surg.
2010) have shown that, when possible, laparoscopic-assisted (minimally invasive)
colon resection has improved short-term outcomes when compared with the
traditional surgical approach. Recovery is quicker and less painful, and the rates of
cancer occurrence are equal. Also available at Orlando Health are laparoscopic handassisted
and robotic-assisted cancer surgeries.
Neoadjuvant (i.e., before surgery) and adjuvant (i.e., after surgery) chemotherapy
are valuable tools in treating more advanced CRC cancers where surgery alone is
not curative. As published by the MOSAIC trial in 2005, newer and more refined
chemotherapeutic regimens have been found to improve cancer-related outcomes
in some patients.
Methods
The Cancer Database at Orlando Health Cancer Program evaluated the analytic
colorectal cancer patients for years 2003-2007 for this annual report. The five-year
survival for this timeframe is not able to be compared to regional or national data at
this time as it has not yet been published. When calculating the five-year survival for
colorectal cases, years 1998-2002 were utilized as this data was able for comparison
to regional and national data. Due to an insufficient number of cases at Orlando
Health within the individual sites of colon, rectum and rectosigmoid cases, these
sites were combined to establish reliable data to report on five-year survival and
compare Orlando Health’s data with the regional and national data.
Results
A review of the data for colon, rectal and rectosigmoid cancers for 2003-2007 at
Orlando Health revealed a total of 1,196 cases. The distribution was as follows:
821 colon, 255 rectal and 120 rectosigmoid cases. Orlando Health is accredited by
the American College of Surgeons (ACoS) as a teaching hospital cancer program
(THCP). All data from Orlando Health was compared to other teaching hospital
cancer programs within the state of Florida and the National Cancer Data Base
(NCDB). The graphs and figures are presented by location of malignancy.
32

Colon Cancer
All years Male Total M Female Total F Total #
Orlando
Health
61.2% 156 38.8% 99 255
Florida 60.0% 585 40.0% 390 975
National 57.8% 1,931 42.3% 14,126 33,436
Sex - Colon Analytic Cases 2003-2007
53.0%
52.1%
51.9%
51.8%
51.2%
49.5%
47.7%
47.9%
48.1%
48.3%
46.0%
Orlando Health Florida National
Male
Female
Table 1
Sex distribution of colon cancers at Orlando Health was comparable to national data.
Age - Colon Analytic Cases 2003-2007
30.0%
22.5%
15.0%
26.5%
27.7%
26.2% 26.1%
23.9%
23.1%
18.2%
18.6% 18.4%
18.6%
16.9%
15.6%
7.5%
0%
8.3%
7.8%
8.2%
3.2% 2.5%
2.8%
0.1%
2.2%
2.2%
0.6%
0.1% 1.4%
0.5% 0.6%
0.1%
Under 20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+
Orlando Health Florida National
Table 2
Age distribution of colon cancers was similar to the national and state data. The
majority of colon cancers were seen during the seventh and eighth decades of life.
33

Colon Cancer
(cont.)
80.0%
Race - Colon Analytic Cases 2003-2007
72.3% 71.5%
68.1%
60.0%
40.0%
20.0%
16.7%
13.2%
18.3%
12.7% 12.3%
4.9%
5.3%
2.6% 2.2%
0%
White Black Hispanic Other - Unknown*
Orlando Health Florida National
Table 3
Racial distribution relative to Hispanic race indicates that Orlando Health (12.67
percent) is higher than national (4.85 percent) data. Hispanic race between Orlando
Health and Florida (12.34 percent) is consistent. This could be due to the higher
population of Hispanics that live in the state of Florida.
Stage at Diagnosis - Colon Analytic Cases 2003-2007
30.0%
27.4%
22.5%
24.9%
22.5%
21.4%
23.7%
22.3%
23.2%
19.5%
19.3%
18.6%
19.5%
18.1%
15.0%
10.2%
7.5%
4.5%
3.3%
6.4%
5.6% 5.4%
0%
0% 0.2% 0.1%
0 I II III IV NA Unk
Orlando Health Florida National
Table 4
Stage III (27.41 percent) colon cancer for Orlando Health was the most common
stage of presentation; Stage II (24.97 percent) and III make up the majority of the
malignancies (52.38 percent). In comparison to the national data, Orlando Health
34

Colon Cancer
(cont.)
encountered a higher percentage of stage II and III colon cancers, but a lower
percentage of carcinoma in situ (stage 0 cancer). This is likely explained by the
referral pattern to our cancer program. Stage IV percentage rates correlated with the
national data.
1st Course of Therapy - Colon Analytic Cases 2003-2007
60.0%
51.8%
50.2%
48.8%
45.0%
30.0%
29.8% 30.2%
25.5%
15.0%
9.5%
6.7%
14.4%
12.9%
11.4%
8.9%
0%
S S & C Other NO
Orlando Health Florida National
Table 5
The first course of therapy was surgery in 51.3 percent of patients with colon cancer,
which correlated with the national data (48.8 percent). Thirty percent of patients had
surgery and chemotherapy as the first course of therapy and 8.9 percent had
no therapy.
35

Colon Cancer
(cont.)
100.0%
Radiation Therapy - Colon Analytic Cases 2003-2007
98.2% 97.5% 97.7%
75.0%
50.0%
25.0%
0%
1.4% 2.3% 2.1%
0% 0% 0.1% 0% 0.1% 0.1% 0.3% 0.2% 0.1%
NO Beam Brachy NOS UNK
Orlando Health Florida National
Table 6
Radiation therapy is not typically the first course of therapy as identified in this
graph, and Orlando Health is comparable to both Florida and national percentages.
Systemic Therapy - Colon Analytic Cases 2003-2007
60.0%
56.7% 56.3%
54.3%
45.0%
30.0%
35.4%
33.7%
30.4%
15.0%
0%
14.3%
9.5%
6.6%
1.3%
0% 0% 0.1% 0% 0.1% 0.1% 0% 0.1% 0.2% 0% 0.6% 0% 0% 0%
0% 0% 0.1%
NO C H I CH CI HI NOS UNK
Orlando Health Florida National
Table 7
Systemic therapy also is not the typical first course of therapy as indicated with 50
percent or more in no therapy, which is comparable to both the state and national
percentages. The second most likely systemic therapy would be for chemotherapy
and is also comparable to both the state and national percentages.
36

Rectal Cancer All years Male Total M Female Total F Total #
Orlando
Health
61.2% 156 38.8% 99 255
Florida 60.0% 585 40.0% 390 975
National 57.8% 1,931 42.3% 14,126 33,436
Sex - Rectal Analytic Cases 2003-2007
70.0%
61.2%
60.0%
57.7%
52.5%
38.8%
40.0%
42.2%
35.0%
17.5%
0%
Male
Female
Orlando Health Florida National
Table 8
No significant difference in the sex distribution was appreciated.
Age - Rectal Analytic Cases 2003-2007
30.0%
27.8%
25.5%
25.8%
25.4%
22.5%
21.9%
23.8%
22.8%
24.2%
20.3%
15.0%
13.2%
12.8%
11.4%
10.9%
9.1%
8.8%
7.5%
3.9%
3.8%
3.7%
0%
0.4%
0%
0.6%
0.7% 0.8%
0% 0.1%
0.8%
Orlando Health Florida National
1.4%
80-89 70-79 60-69 50-59 40-49 30-39 20-29 Under 20 90+
37

Rectal Cancer
(cont.)
Table 9
No significant difference in the age distribution between our data compared with
state and national data. As with colon cancer, most cases occurred during the sixth
and seventh decades of life.
Race - Rectal Analytic Cases-Florida 2003-2007
80.0%
79.2%
71.4%
73.7%
60.0%
40.0%
20.0%
13.4%
11.4%
8.8%
13.7%
9.5%
5.7%
3.5%
2.5%
7.1%
0%
White Black Hispanic Other - Unknown*
Orlando Health Florida National
Table 10
As with colon cancer, Orlando Health’s cancer program had a higher proportion of
Hispanic patients with rectal carcinoma, when compared to national data, but with
similar racial distribution to Florida which ranks seventh in total population of the
Hispanic race in the United States and third in the population growth of Hispanics.
38

Rectal Cancer
(cont.)
30.0%
Stage at Diagnosis - Rectal Analytic Cases 2003-2007
27.1% 26.8%
24.8%
24.3%
22.5%
22.4%
19.5%
18.4%
22.4%
20.9%
15.0%
13.3%
15.7%
13.2%
16.5%
10.2%
9.6%
7.5%
5.7% 5.9%
2.7%
0%
0%
0.3% 0.3%
0 I II III IV NA Unk
Orlando Health Florida National
Table 11
Orlando Health has a higher percentage of stage II and stage III rectal cancers
when compared to the national data. “NA” describes patients who had insufficient
information available to determine the stage of disease.
1st Course of Therapy - Rectal Analytic Cases 2003-2007
50.0%
45.1%
41.7%
37.5%
35.4%
29.8%
27.6%
25.0%
24.3%
12.5%
7.8%
6.1%
5.2%
8.5%
7.4% 7.2%
7.8%
4.5%
8.9%
6.2%
12.1%
10.5%
0%
S S & C R & C S, R, & C Other NO
Orlando Health Florida National
Table 12
Data for Orlando Health suggests that a higher percentage of surgical patients receive
chemotherapy and radiation therapy when compared to national data (45 percent
and 35 percent, respectively).
39

Rectal Cancer
(cont.)
60.0%
Radiation Treatment - Rectal Analytic Cases 2003-2007
55.7%
51.1%
52.0%
45.0%
43.9%
46.3%
46.7%
30.0%
15.0%
0%
1.2% 1.5%
0% 0.2% 0.1%
0%
0.4% 0.1% 0.2%
UNK NOS Brachy Beam NO
National
Florida
Orlando Health
Table 13
Orlando Health data shows that Beam Radiation Therapy was given more frequently
(55.69 percent) as compared to national data (46.69 percent).
Systemic Therapy - Rectal Analytic Cases 2003-2007
70.0%
61.9%
59.9%
52.5%
52.4%
35.0%
30.1%
35.1%
38.2%
17.5%
0%
6.9%
5.4%
3.2%
0% 0% 0.1% 0% 0.1% 0.1% 0% 0.2% 0.1% 0.4% 0.6% 0.5%
1.9%
0.8% 0.2%
NO C H I C & H C & I NOS UNK
Orlando Health Florida National
Table 14
A higher percentage of Orlando Health patients (61.96 percent) received systemic
chemotherapy when compared to national data (52.40 percent).
40

Rectosigmoid Cancer
30.00%
Age - Rectosigmoid Junction Analytic Cases 2003-2007
28.3% 28.2%
24.2% 24.2%
24.5%
24.2%
22.50%
21.7%
22.1%
21.1%
15.00%
13.3%
9.6%
11.8%
11.9%
11.2%
7.50%
0%
5.8%
4.2%
4.0%
3.1%
2.5%
0.9%
1.7%
0.7%
0.9%
0% 0% 0%
0%
Under 20 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+
Orlando Health Florida National
Table 15
The age distribution at Orlando Health was similar to that of the state, except for
patients in their ninth decade of life, where we saw a lower percentage of patients (5
percent versus 11 percent, respectively).
41

Rectosigmoid Cancer
(cont.)
All years Male Total M Female Total F Total #
Orlando
Health
52.5% 63 47.5% 57 120
Florida 55.4% 179 44.9% 144 323
National 53.6% 6,141 46.4% 5,314 11,455
Sex - Rectosigmoid Junction Analytic Cases 2003-2007
60.00%
52.5%
55.4%
53.6%
45.00%
47.5%
44.5%
46.4%
30.00%
15.00%
0%
Orlando Health Florida National
Male
Female
Table 16
No significant difference in the sex distribution was appreciated.
42

Rectosigmoid Cancer
(cont.)
40.00%
Stage at Diagnosis - Rectosigmoid Junction Analytic Cases 2003-2007
30.00%
26.4%
28.5%
30.8%
26.7%
20.00%
19.3%
21.1%
22.3%
21.1%
19.9%
23.5%
21.7%
15.0%
10.00%
9.3%
0%
3.9%
3.1%
1.5% 1.7%
0.4% 0.1% 0% 0%
Unk NA IV III II I 0
National
Florida
Orlando Health
Table 17
Orlando Health data suggests that we are seeing more patients with stage II (24.97
percent) and stage III (24.41 percent) rectosigmoid cancers when compared to the
national data (stage II 22.57 percent and stage III 23.33 percent). Orlando Health is
less regarding stage IV (18.15 percent) when compared to national (19.59 percent)
and state (23.25 percent).
Race - Rectosigmoid Junction Analytic Cases - Orlando Health 2003-2007
80.00%
75%
73.9% 74.4%
60.00%
40.00%
20.00%
13.3%
15.5%
13.3%
7.5%
7.1%
5.7%
4.7%
3.4%
6.7%
0%
White Black Hispanic Other - Unknown*
Orlando Health Florida National
Table 18
Similar to the data for colon and rectal cancer, Orlando Health sees a higher
percentage of Hispanic patients with rectosigmoid cancers when compared to the
national data. However, this was inversely true for the African American population,
where we saw a lower percentage.
43

Rectosigmoid Cancer
(cont.)
1st Course of Therapy - Rectosigmoid Junction Analytic Cases 2003-2007
50.00%
41.7% 41.2%
37.50%
38.3%
25.00%
21.7%
19.5% 19.3%
19.2%
22.3%
18.1%
12.50%
11.7%
7.7%
11.9%
5.8%
9.3%
12.3%
0%
S S & C S, R, & C Other NO
Orlando Health Florida National
Table 19
The most common first course of treatment was surgery. Orlando Health was similar
in all modalities when compared to the national average.
Radiation Therapy - Rectosigmoid Junction Analytic Cases 2003-2007
80.00%
77.2%
75.8%
73.9%
60.00%
40.00%
20.00%
25.7%
23.3%
21.7%
0%
0.2%
0.3% 0.8% 0.9%
0% 0%
0.1% 0% 0%
UNK NOS Brachy Beam NO
National
Florida
Orlando Health
Table 20
Radiation therapy is not the typical first course of therapy. All three entities had 73
percent or more patients receiving no radiation therapy.
44

Rectosigmoid Cancer
(cont.)
50.00%
Systemic Therapy - Rectosigmoid Junction Analytic Cases 2003-2007
46.8%
44.7%
44.3% 44.2%
43.2%
37.50%
36.3%
25.00%
12.50%
11.7%
11.9%
7.7%
0%
1.2%
0% 0% 0.1% 0% 0% 0.1% 0% 0% 0.1% 0%
0.6%
0% 0% 0.3%
NO C H I C & H C & I NOS UNK
Orlando Health Florida National
Table 21
The percentage of patients receiving chemotherapy at Orlando Health was similar to
that of the national data.
Discussion
When comparing Orlando Health’s teaching institution data from 2003-2007
to that of published NCDB data, it is evident that our sex and age distribution
of colon, rectal and rectosigmoid cancers were similar. The racial distribution
was weighted toward the Hispanic population across all three cancer subtypes.
We found similar trends when comparing Orlando Health to the NCDB
published data in the following areas: surgery as first course therapy in colon and
rectosigmoid cancers; percentage of patients receiving chemotherapy or radiation
therapy in colon and rectosigmoid cancers. Across all subtypes, Orlando Health
cared for more patients presenting with either stage II or stage III cancers, when
compared to the national average. This is likely explained by the inherent referral
patterns to Orlando Health’s cancer center. Variations in treatment were noted in
management of rectal carcinoma, where a higher percentage of surgical patients
receive chemotherapy and radiation therapy at Orlando Health when compared to
national data.
45

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46

Glossary
Adjusted Survival Rate — A calculation that takes into account whether the
patient died of cancer.
American College of Surgeons (ACoS) — An association of surgeons that
ensures patient access to high-quality and effective care.
Analytical (A) — Describes cases of cancer that were initially diagnosed and/or
received their first course of treatment at one of the above listed facilities.
Cancer Committee — An organized group of physicians and non-physicians who
direct the long-range planning and general activities of the oncology services in a
healthcare organization. At Orlando Health, the cancer committee is referred to as
the Oncology Policy and Planning Committee.
Cancer Conference — A cancer conference is a meeting of multidisciplinary
professionals where the diagnosis and treatment needs of the patient are discussed.
Casefinding — The process of systematically identifying all cases eligible for
inclusion in the Cancer Database.
Commission on Cancer (CoC) — A branch of the American College of Surgeons
that surveys and accredits cancer programs.
Florida Cancer Data Systems (FCDS) — Florida’s statewide, population-based
cancer registry that has been collecting incidence data since 1981.
Follow-up — The process of annually monitoring the patient’s health status.
Follow-up Rate — A calculation of the percentage of patients who have current
information (within 15 months) on their health status.
Histology — The study of microscopic structure of tissue.
National Cancer Data Base (NCDB) — A joint project of the American College
of Surgeons Commission on Cancer and the American Cancer Society. The goal
of the NCDB is to present an annual summary of care that patients diagnosed and
treated for cancer receive at hospitals and centers throughout the country.
Non-Analytical (NA) — Describes cases of cancer that are diagnosed and treated
elsewhere and receive subsequent care at one of the facilities listed above. Also
includes cases that were treated more than four months after diagnosis or cases first
diagnosed at autopsy.
Prospective — Refers to the discussion and recommendation of disease
management.
Reference Date — The start date established for a registry, usually January 1 of a
given year, after which all eligible cases must be entered in the registry.
Stage — The extent of cancer is shown through exams, tests or surgery. The stage
of disease is recorded using the AJCC staging system: Tumor, Nodes and Metastasis
and Surveillance, Epidemiology and End Results (SEER) staging. Staging conveys
anatomic extent of disease or prognostic information about an individual case.
Survival Rate — A calculated number or percentage of persons in a defined
population who remain alive during a specified time interval.
6100-114417 9/10
47