Cancer Update November 2014

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2014

Issue No. 30

Robert Witt, M.D., and Neil Hockstein, M.D., of the Head and Neck Cancer Multidisciplinary Center

IN TH I S I SSU E 5 INITIATIVES: NCI grant will transform community cancer care 7 URGENT CARE: Onsite unit helps patients avoid the Emergency Room 8 IN THE LAB: New technology spurs the hunt for cancer

The Helen F. Graham Cancer Center & Research Institute recognized as national model for treatment of head and neck cancers When Wilmington Realtor Brian Ferreira was diagnosed with oral cancer, he could have gone just about anywhere for treatment. He chose the Head and Neck Cancer Multidisciplinary Center (MDC) at the Helen F. Graham Cancer Center & Research Institute.

“I went to Philadelphia for a second opinion, but I came back to the Graham Cancer Center for my care, and I was not disappointed,” he said. “I never felt like just another patient. My doctors and the entire MDC team took a personal interest in my very personal illness.”

At the Head and Neck MDC, a surgeon, medical oncologist and radiation oncologist team with health professionals from every pertinent discipline – a nurse navigator and research CONTINUED

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Advanced & Individualized Care

GRAHAM CANCER CENTER RECOGNIZED AS NATIONAL CARE MODEL | CONTINUED

nurse, a dental expert, a speech pathologist, a dietitian, a health psychologist and a social worker. The entire team has one focus: an effective treatment plan for each patient’s particular type of cancer.

This unique model of multidisciplinary cancer care, introduced 10 years ago at the Helen F. Graham Cancer Center & Research Institute, is the standard for leading institutions around the country and abroad. Studies show that patients do better in this type of multidisciplinary care setting.

“Given the multiple primary treatment modalities used to treat head and neck cancers, participation by a comprehensive multidisciplinary core of physicians and specialists is essential,” said MDC Director Robert Witt, M.D. In addition to his clinical work, Dr. Witt is an internationally recognized researcher and book editor in salivary gland diseases and thyroid cancer.

Recently he received, as principal investigator, a fouryear, $2.5 million R01 National Institute of Health grant to continue groundbreaking efforts to generate artificial salivary glands in the laboratory. Dr. Witt hopes this research will soon improve the quality of life for patients whose own salivary glands are damaged by radiation therapy.

Next generation medicines target more prolific cancers Incidence of head and neck cancer is skyrocketing, particularly for mouth cancers induced by the human papilloma virus or HPV. The good news, according to Medical Oncologist Charles Schneider, M.D., is, “These viral-induced cancers have a significantly better prognosis compared to cigarette and alcohol-induced head and neck cancer, and also respond extremely well to chemotherapy and radiation.”

Most patients with regionally advanced head and neck cancers (both HPV-positive and negative) experience high cure rates when treated with a combination of chemotherapy and radiation. “We have transformed a disease with an historically dismal prognosis into one that is highly treatable and usually curable,” said Dr. Schneider.

New biologic agents offer more targeted therapy with fewer side effects than traditional chemotherapy drugs.

Sophisticated radiation technologies such as image-guided intensity modulated radiation therapy and volumetric modulated arc therapy (soon to be instituted) dramatically reduce treatment times and optimize radiation doses to precisely target cancer cells.

CONTINUED

COORDINATING A PLAN The Head and Neck MCD team meets to discuss a patient’s plan of care ensuring what is the best course for the patient.

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Less invasive surgical techniques shorten hospital stays and improve recovery. For some types of hard-to-reach cancers, for example, those located in the oral and nasal cavities, minimally invasive da Vinci® robotic surgery may be the best option. Otolaryngologist and Surgeon Neil Hockstein, M.D., pioneered this technology nearly a decade ago while at the University of Pennsylvania School of Medicine and has published extensively on its capabilities.

“One tremendous advantage of the Head and Neck MDC,” he explained, “is that the patient’s physicians and other health professionals meet face-to-face. Together we can coordinate their plan of care and actually talk to one another about what is best for the patient.”

This process not only promotes best practices, but shortens time to treatment and enables patients and their family members to meet with their entire cancer care team in a single visit.

“When Dr. Hockstein, my surgeon, explained all the reasons why surgery was not the best way to treat my cancer, and that the MDC offered better options, it really impressed me,” Ferreira said. “It raised my comfort level to know I was getting an honest picture of my condition and that the Graham Cancer Center is where I would get the best care.”

At the MDC, each patient has a personal guide through the cancer treatment process — a certified oncology nurse navigator, who collaborates with the rest of the team to help navigate, answer questions and respond to concerns.

A certified research nurse enrolls patients in clinical trials and follows them throughout their trial experiences.

Depending on the patient’s individual needs, experts in other fields may join the team. In addition, the Graham Cancer Center offers a host of specialized services, including survivorship, pain and symptom management, genetic counseling, wellness and well-being programs, pastoral care,

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One tremendous advantage of the Head and Neck MDC, is that the patient’s physicians and other health professionals meet face to face.

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NE I L H O C K STE IN, M.D.

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We have transformed a disease with an historically dismal prognosis into one that is highly treatable and usually curable.

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CHARLES SCHNEI DER, M.D.

smoking cessation and a follow-up clinic for young adults who have survived childhood cancer.

For Ferreira, the journey was never solitary. “Throughout my treatment, I genuinely felt that all the people I worked with at the Graham Cancer Center really cared about my prognosis and would help me get to where they expected me to be,” he said.

Leveraging the latest research findings As one of only 34 community sites in the nation selected by the National Cancer Institute as a Community Oncology Research Program (NCORP), the Graham Cancer Center offers access to state-of-the-art clinical studies for patients with both early and advanced head and neck cancers.

Studies underway at Christiana Care through the NCI clinical trials program include testing a targeted immunologic agent called cetuximab that interacts with radiation as a sensitizer and enlists the immune system to disrupt cancer growth and metastases; afatinib to treat recurring cancers and bevacizumab for metastatic disease. Radiation Oncologist Adam Raben, M.D., recently introduced a Phase I trial in collaboration with University of Colorado Health Science Center incorporating a targeted agent (PI3K) with chemotherapy for HPV cancers.

Evidence suggests that patients do better when enrolled in a clinical trial and when treated at centers with high clinical trial accruals. Currently 24 percent of patients at the Helen F. Graham Cancer Center participate in clinical trials — well above the national average. ¤ November 2014

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Graham Cancer Center hosts first Tissue Engineering Summit Researchers on the fast track to developing artificial salivary glands could speed relief from some radiation therapy side effects The largest group in the nation collaborating to create artificial salivary glands in the laboratory gathered at the Helen F. Graham Cancer Center & Research Institute in August 2014 to discuss their progress. Principal Investigator Robert Witt, M.D., director of the Multidisciplinary Head and Neck Cancer Center, and Swati Pradhan Bhatt, Ph.D., director of Tissue Engineering at the Center for Translational Cancer Research, hosted the two-day summit attended by team members from the University of Delaware’s Materials Engineering and Biological Sciences Departments, Rice University in Houston and Allegheny Health System in Pittsburgh. Also attending were scientists from the National Institutes of Health, which awarded the team $2.5 million to fund the project over the next four years. The research team has grown to include some 25 investigators, under the leadership of Dr. Witt and co-principal investigators Cindy Farach-Carson, Ph.D., a biologist at Rice University and Xinqiao Jia, Ph.D., a materials engineer from the University of Delaware. ¤

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Paula Furtado Office Supervisor for Genetics, Oncology Nutrition and Psychosocial & Survivorship, at the Helen F. Graham Cancer Center & Research Institute

As an office supervisor for several different cancer care programs, I know that promoting teamwork and good communication is key to delivering optimum patient care. It is imperative that as a team, we give our patients the help they need in a timely manner, but also in a way that is comforting and reassuring. I am extremely proud to be a member of this team that works hard to give our best to our patients and their families. ¤

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Improving Outcomes

National Cancer Institute Research grant will transform community cancer care Medical Oncologist Stephen S. Grubbs, M.D., is the NCORP principal investigator at the Helen F. Graham Cancer Center & Research Institute

The National Cancer Institute has selected Christiana Care’s Helen F. Graham Center & Research Institute to join its Community Oncology Research Program (NCORP), an elite network of cancer centers in communities throughout the United States.

A five-year, $8.2 million grant from NCORP bolsters Graham Cancer Center initiatives to bring leading-edge cancer screenings, prevention, control, treatment and imaging research trials to more people in places closest to where they live and work.

The Graham Cancer Center is one of only 34 NCORP Community Sites joined by 12 Minority/Underserved Community Sites that will implement the latest, most scientifically advanced clinical research designed and led by NCORP. These clinical trials will bring added opportunity to test new technologies and strategies to fight cancer. They will also enable research on how cancer care is delivered in today’s changing health care environment, all with an eye toward improving outcomes and reducing disparities of care.

AN ELITE GROUP The Graham Cancer Center is one of only 34 NCORP Community Sites that will implement the latest, most scientifically advanced clinical research.

“Making quality cancer care more accessible to our patients is the hallmark of Christiana Care’s cancer program and mission,” said Nicholas J. Petrelli, M.D., Bank of America CONTINUED November 2014

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NCI RESEARCH GRANT | CONTINUED

endowed medical director of Christiana Care’s Helen F. Graham Cancer Center & Research Institute. “In partnership with NCORP, we can change the landscape of cancer care delivery in Delaware and throughout the country in similar communities, where we know 80 percent of patients receive their cancer care.”

The Graham Cancer Center is one of the original NCI-selected Community Cancer Center sites (NCCCP) and has been a leader in NCI’s Community Clinical Oncology Program (CCOP).

grant from NCORP bolsters Graham Cancer Center initiatives bringing leading-

NCORP builds on and replaces these two previous NCI community-based clinical research programs (NCCCP, CCOP) that have helped drive down cancer rates. In 2002, Delaware had the highest cancer mortality in the nation. Today, the First State is number 14 on that list, and cancer mortality rates for both men and women are dropping nearly twice as fast as the national average.

edge cancer screenings,

Christiana Care Medical Oncologist Stephen S. Grubbs, M.D., is the NCORP principal investigator at the Graham Cancer Center. “These programs show that when local physician investigators collaborate on national community-based studies, our patients benefit greatly because they gain access to the most promising cancer fighting strategies without having to leave the comfort of familiar surroundings,” said Dr. Grubbs.

“Membership in NCORP is a natural progression for our program,” he said. ¤

people in places closest to

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In partnership with NCORP, we can change the landscape of cancer care delivery in Delaware and throughout the country in similar communities, where we know 80 percent of patients receive their cancer care.

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NIC HOL AS J . PE TR E L L I , M.D.

Bank of America endowed Medical Director The Helen F. Graham Cancer Center & Research Institute

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prevention, control, treatment and imaging research trials to more where they live and work.

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The Graham Cancer Center Medical Support Unit

On-site Medical Support Unit helps patients avoid preventable Emergency Room visits

Frank Beardell, M.D., and Donna Kerr, RN, BSN, examine a patient on the Bone Marrow Transplant Unit.

Lindsey O’Donnell, M.D., and Nicole Stipo, ANP-BC, see patients at the Medical Support Unit

It is 8 a.m. Monday morning at the Helen F. Graham Cancer Center & Research Institute when Nurse Practitioner Nicole Stipo, ANP-BC, gets the call. A cancer patient with a history of cardiac problems has arrived for radiation therapy feeling short of breath.

A few minutes later and down the hall, the scene changes.

Inside the Medical Support Unit, after taking an X-ray to rule out pneumonia, Stipo has administered a rescue inhaler, helping the patient breathe easier, relax and feel better.

“When patients at the Graham Cancer Center need prompt medical treatment, and their doctors are not available, we can see them at the Medical Support Unit right here in the building,” Stipo said. “We can also do CT scans and administer IV fluids if necessary.” A visit to her office helps

patients avoid the Emergency Department or even hospital admission.

Family Medicine’s Lindsey O’Donnell, M.D., collaborates as the Unit’s medical director. She sees patients on-site one afternoon a week.

“Patients who are in treatment at the Graham Cancer Center on a routine or even a daily basis have difficulty finding time to schedule appointments with their primary care doctors,” she said. “What complicates matters is that any co-morbidities they may have, such as diabetes, high blood pressure, or heart disease, may become active during their therapy for one reason or another and require our prompt attention.”

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ON SITE MEDICAL SUPPORT UNIT | CONTINUED

Symptoms caused by the side effects of cancer therapy can also lead patients to seek relief at the Medical Support Unit.

For that reason, Stipo regularly attends one or more of the multidisciplinary cancer clinics in session weekly at the Graham Cancer Center. She works closely with the patient’s primary care doctor and cancer specialists to coordinate treatment and follow-up. If patients do not have a primary care doctor, she will try to connect them with one.

“Patients undergoing treatment for a head or neck cancer, for example, may come in for relief from mouth dryness, a sore throat or even a secondary infection that won’t wait for a visit to their doctor,” Stipo said. “Whether their need is acute or simply an annoyance, we are close by for immediate care.” ¤ The Medical Support Unit, located on the first floor, is open from 8 a.m. to 4 p.m., Monday through Thursday for patients undergoing treatment at the Helen F. Graham Cancer Center & Research Institute.

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When patients need prompt medical treatment, and their doctors are not available, we can see them at the Medical Support Unit right here in the building.

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NI COLE STI PO, ANP-BC

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Bringing New Analysis to Different Types of Cancers

Center for Translational Cancer Research installs Tissue Microarray technology to spur the hunt for cancer clues The Center for Translational Cancer Research (CTCR) at the Helen F. Graham Cancer Center & Research Institute can now produce tissue microarrays or TMAs. Picture hundreds of tiny tumor samples preserved for analysis on a single glass slide.

Funding support for installing this leading-edge technology at the CTCR comes as part of a translational research collaboration between the Graham Cancer Center and The Wistar Institute in Philadelphia.

For Senior Clinical Scientist Jennifer Sims-Mourtada, Ph.D., who is looking for markers of aggressive breast cancers, TMAs can make the process cheaper and faster. “With TMAs we can analyze hundreds of tumor markers using the same

set of specimens all at the same time,” she said. This type of rapid throughput analysis can be a game changer in the drive to translate new findings from the lab into clinical practice.

The Graham Cancer Center’s Tissue Procurement Center provides fresh tissue samples and access to several thousand banked specimens for Wistar scientists. Several Wistar scientists are collaborating with physician investigators at Christiana Care to change what we know about many different types of cancers. In addition, the Tissue Procurement Center houses thousands of paraffin wax blocks of different cancer tumor types, a valuable resource for TMA research.

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ADVANCED TECHNOLOGY Hundreds of tiny tumor samples can be preserved for analysis and can be a game changer in translating new findings from the lab into clinical practice.

Histotechnologist Marlene Goins

How TMAs are produced As a starting point, histotechnologist Marlene Goins is preparing TMAs from wax blocks of ovarian and breast tumors banked at Christiana Care.

Goins uses a fine, hollow needle to extract core samples, some as tiny as a pencil tip, and place them into a recipient wax block that can hold hundreds of samples. These can

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There are literally hundreds of thousands of tissue samples banked at Christiana Care that we could use to produce TMAs for a multitude of research interests.

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be multiple samples from the same tumor or samples from different tumors and different donors. Researchers can request the make-up of each block according to their own study requirements, specifying the kinds of tumors, the size of each sample and the donor characteristics they need.

Once the recipient wax block is completed, Goins uses the CTCR’s newly acquired microtome to cut the block into hundreds of tissue-paper-thin slices. Each slice is a mirror grid of all the tissue cores in the original block. She affixes a single slice per glass slide, then packages the slides and sends them to the research lab for immunohistochemical and other sophisticated methods of analyses.

“There are literally hundreds of thousands of tissue samples banked at Christiana Care that we could use to produce TMAs for a multitude of research interests,” said Abraham Joseph, MA, MBA, CG, MB, DLM(ASCP), director of Molecular Diagnostics, Anatomic Pathology and Translational Cancer Research. “After 10 years, these specimens are no longer needed for diagnostic purposes, but transferring them to TMAs will preserve them as invaluable research resources.” ¤

AB R AHAM J OSE PH, MA, MBA, C G, MB , DL M( AS CP) November 2014

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Specialists in your corner

Welcome to the newest members of the Helen F. Graham Cancer Center & Research Institute Jenny Petkova, M.D., Hematologist, has broad experience in both benign and malignant blood disorders, blood banking and transfusion medicine. In July, she joined Delaware Clinical & Laboratory Physicians (DCLP), P.A., at the Graham Cancer Center. She also provides medical oversight for Christiana Care’s Blood and Bone Marrow Stem Cell Transplant Program and blood banking services. She is fellowship trained in Hematology-Oncology and Transfusion Medicine, and is excited to once again work with her fellowship mentor DCLP Hematologist Michael W. Lankiewicz, M.D. ¤

Amro H. Shihabi, D.M.D., M.D., Oral and Maxillofacial Surgeon, joined the Christiana Care Department of Oral and Maxillofacial Surgery and the Oral & Facial Surgery Faculty Practice in August. Dr. Shihabi is fellowship trained in maxillofacial oncology and microvascular reconstruction. ¤

Clinical capsule

Best practices for treating small cell lung cancer

Accreditation by the Commission on Cancer requires that Christiana Care’s Cancer Program perform an annual assessment of evaluation and treatment planning. For 2014, program leadership selected to evaluate the use of prophylactic brain radiation to our population of small cell lung cancer patients. Radiation may be given to the brain after other treatments to help lower the chances that the cancer will spread there. This is a recommended treatment guideline from the National Comprehensive Cancer Network (NCCN). At Christiana Care, upon chart review, 46.6 percent of the patients received prophylactic radiation. 53.3 percent of the group did not receive the treatment. Of the cases that did not follow the NCCN-recommended treatment, the vast majority of cases involved disease that was too advanced or patients who were too debilitated. In all, only 20 percent of cases did not follow the suggested NCCN treatment guidelines for reasons that are unknown. ¤

The Graham Cancer Center is a top enroller nationally in clinical trials, which may offer the best options for treatment to qualified patients. To learn more, contact Cancer Research at 302-623-4450.

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CHRISTIANA CARE CANCER PROGRAM 2013 ANALYTIC* CASE DISTRIBUTION YEAR CASES SEEN AT CHRISTIANA CARE HEALTH SYSTEM PRIMARY SITE

2013 CASES BY AJCC STAGE GROUPS

2005

2006

2007

2008

2009

2010

2011

2012

2013

0

I

II

III

IV

ORAL

67

51

68

73

78

87

74

82

96

2

29

10

15

33

7

Tongue

21

18

26

25

26

29

25

27

26

1

9

1

6

8

1

Mouth

36

25

29

41

45

47

34

48

62

1

20

8

6

21

6

Pharynx

10

8

13

7

7

11

15

7

8

0

0

1

3

4

0

DIGESTIVE

401

444

460

498

442

433

473

460

502

13

93

116

120

132

28

Esophagus

15

18

29

36

29

20

39

30

30

0

6

4

12

8

0

Stomach

32

35

35

34

25

32

30

36

42

1

9

4

10

14

4

Small Intestine

UNK/NA

7

8

8

16

15

13

18

21

8

0

1

1

3

3

0

Colon

171

178

168

179

158

155

138

144

161

9

30

46

42

30

4

Rectum/Rectosigmoid

67

81

76

80

68

72

74

58

76

2

23

16

22

13

0

Liver/IHBD

21

29

35

30

32

36

36

47

46

0

8

3

10

12

13

Pancreas

63

67

69

83

77

69

85

75

90

0

10

34

10

35

1

Other Digestive

25

28

40

40

38

36

53

49

49

1

6

8

11

17

6

RESPIRATORY

452

477

439

465

446

521

469

429

470

1

129

37

107

187

9

Larynx

35

20

21

28

32

29

30

25

29

1

4

5

8

10

1

Lung

406

451

401

421

399

479

426

395

431

0

125

31

97

174

4

Mesothelioma

8

5

9

7

6

8

10

8

5

0

0

1

2

1

1

Other Respiratory

3

1

8

9

9

5

3

9

5

0

0

0

0

2

3

BONE & CONNECTIVE TISSUE

17

24

28

25

28

20

32

20

23

0

7

2

7

5

2

Bone/Joints

6

5

4

7

5

5

5

6

5

0

1

0

0

2

2

Connective/Soft Tissue

11

19

24

18

23

15

27

14

18

0

6

2

7

3

0

MELANOMA

116

121

118

145

160

136

145

108

126

21

57

21

15

5

7 5

Other Skin Cancer

6

7

9

13

6

7

8

13

12

0

4

1

2

0

BREAST

557

534

597

639

703

652

698

747

789

173

320

194

66

27

9

FEMALE ORGANS

182

194

229

198

228

202

257

252

267

3

153

22

48

31

10

Cervix

37

27

48

33

41

41

33

37

30

0

11

4

9

6

0

Uterus

98

103

113

101

110

110

154

152

157

2

108

9

20

12

6

Ovary

41

47

54

37

52

39

53

41

51

0

18

6

15

10

2

Other Female Organs

6

17

14

27

25

12

17

22

29

1

16

3

4

3

2

MALE ORGANS

328

381

407

401

302

285

225

213

218

0

63

122

14

17

2

Prostate

316

368

393

390

290

274

217

204

207

0

55

120

14

16

2

Testis

10

11

13

11

10

8

8

7

9

0

8

1

0

0

0

Other Male Organs

2

2

1

0

2

3

0

2

2

0

0

1

0

1

0

URINARY

190

179

188

179

199

215

216

216

218

75

80

19

17

22

5

Bladder

91

100

109

83

104

105

124

115

128

71

26

14

6

10

1

Kidney/Renal Pelvis

90

68

72

89

90

105

89

96

80

2

52

3

9

11

3

Other Urinary

9

11

7

7

5

5

3

5

10

2

2

2

2

1

1

BRAIN/CNS

92

116

113

123

116

112

102

106

90

0

0

0

0

0

90

ENDOCRINE

94

72

95

117

129

133

144

125

142

0

92

9

10

8

23

Thyroid

77

60

69

93

94

108

131

110

120

0

92

9

10

7

2

Endocrine/Other

17

12

26

24

35

25

13

15

22

0

0

0

0

1

21

LEUKEMIA

58

60

68

79

37

53

57

76

46

0

0

0

0

0

46

Hodgkin Lymphoma

23

18

10

20

20

25

15

9

16

0

5

4

3

4

0

Non-Hodgkin Lymphoma

96

102

102

130

126

97

108

86

97

0

22

23

17

35

0

Myeloma

18

25

26

39

28

25

28

34

36

0

0

0

0

0

36

ALL OTHER/UNDEFINED

44

58

58

74

64

79

63

64

54

0

0

0

0

0

54

2741

2863

3015

3218

3112

3082

3114

3048

3202

288

1054

580

441

506

333

TOTAL

*Analytic cases involve patients with new diagones or who were newly treated by Christiana Care Health System in 2013.

PRSRT STD U.S. POSTAGE PAID WILMINGTON DE PERMIT NO. 357

P.O. Box 1668 Wilmington, DE 19899-1668

One of the original 14 cancer centers in the nation selected for the National Cancer Institute Community Cancer Centers Program.

The Multidisciplinary Cancer Centers at the Helen F. Graham Cancer Center & Research Institute offer comprehensive care and treatment.

Breast Cancer Bone Sarcoma Genetic Risk Assessment Genitourinary Cancer Head & Neck Cancer/Thyroid Hepatobiliary/Pancreatic Cancers Lymphoma Medical Support Melanoma/Soft Tissue Sarcoma Neuro/CyberKnife Ostomy Care Rectal/Anal Cancers Skin Screening Spinal Tumor & Metastatic Lesion Thoracic/Esophageal Cancers Young Adult Follow-up

Learn how we are transforming cancer care and treatment at www.christianacare.org/cancer Christiana Care is a private, not-for-profit regional health care system that relies in part on the generosity of individuals, foundations and corporations to fulfill its mission. To learn more about our mission, please visit christianacare.org/donors.

Cancer Update is produced by Christiana Care Health System. Š Christiana Care Health System, 2014. All rights reserved.

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