M.D. Update October 2011 - Oncology by Mentelle Media LLC

The Business Magazine of Kentucky Physicians and HealthCare Administrators October 2011

BURDEN & Opportunity

Trends in Oncology Care M.D. Update travels across the state to investigate how trends in oncology care shape the day-to-day practice of multidisciplinary cancer centers large and small.

Also inside

Volume 2, Number 9

 Heavy

Legislative Agenda for KMA President Shawn Jones  A Legal View on Scope of Practice  Up-close

Look at Head and Neck Cancer Reconstruction

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Contents

October 2011 Volume 2, Number 9

4 letters

cover story

5 Headlines with new KDA president Dr. Shawn Jones 7 Finance 8 law 10 insurance 12 practical insight Featuring ENT/DMD Dr. Wayne B. Colin 15 cover story 25 news 31 events

High Incidence & the Complexity of Care

OBFCC Louisville South End is devoted to serving an underserved population. page 15

BURDEN & Opportunity ď ľ Trends in Oncology Care

On the Cover: Cancer and Blood Specialists: (l-r) Subhash P. Sheth, MD; Michael G. Carroll, MD; M. Iltaf Khan, MD; and Vijay M. Raghavan, MD.

M.D. Update travels across the state to investigate how trends in oncology care shape the day-to-day practice of multidisciplinary cancer centers large and small. 18 Physical & Emotional Needs of Patients

20 Technological Advancements & Improved Survivals

22 Compassionate, Patient Focused Care M.D. Update 1

Volume 2, Number 9 October 2011

To participate in M.D. UPDATE, contact publisher Gil Dunn. | gdunn@md-update.com | (859) 309-0720

Photographers

Publisher

Gil Dunn gdunn@md-update.com Editor in Chief

Megan Campbell Smith mcsmith@md-update.com Sales Manager

Bias Tilford bias.tilford@md-update.com Associate Editors

Greg Backus John Cowgill

Kirk Schlea Liz Haeberlin Writers

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Jennifer S. Newton Nicole V. Candler Graphic Designer

James Shambhu art@md-update.com

Contributors: Lisa English-Hinkle Scott Neal Calvin Rasey

Bias Tilford bias.tilford@md-update.com Business Services:

Wesley Shears wshears@md-update.com

Integrated Physician Marketing:

Gil Dunn gdunn@md-update.com

Mentelle Media, LLC

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M.D. Update is peer reviewed for accuracy. However, we cannot warrant the facts supplied nor be held responsible for the opinions expressed in our published materials. Copyright 2011 Mentelle Media, LLC. Contact Mentelle Media for information on obtaining reprints. Individual copies of M.D. Update are available for $7.95.

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Letters to the editor

Benefits of Commission on Cancer Accreditation Thank you for this opportunity to address physicians in Kentucky about the benefits of Commission on Cancer accreditation through the American College of Surgeons. The Commission on Cancer was established by the American College of Surgeons in 1922. It is a multidisciplinary group that establishes standards to ensure quality and comprehensive cancer care delivery; conducts surveys to assess compliance; collects standardized data to measure cancer care quality; uses that data to monitor treatment patterns and outcomes; and develops effective educational interventions to improve

cancer prevention, early detection, cancer care delivery, and outcomes. Accredited programs receive national recognition. Joint Commission, American Cancer Society, CMS, Medicaid, Aetna, NQF, and the National Cancer Institute have established performance measures that recognize your accreditation. Participation in the National Cancer Data Base and access to Comparison Benchmark Reports and other resources and tools enable Commission-accredited programs to compare their quality of care and improve performance based on nationally recognized quality measures. Public awareness is an important part of being an accredited program. Free promotion and national exposure are available to

accredited programs. All of the above all are excellent reasons to consider helping your health care facility achieve accreditation. Most of all, you can be assured that your facility is providing high-quality, multidisciplinary cancer care to your community. The use of multidisciplinary teams has been shown in many studies to improve outcome in cancer patients. If you or your facility is interested in learning more about accreditation, that information is available on the CoC website at http://www.facs.org/cancer/coc/seekingaccred.html. Mary T. Legenza, MD FACS Ky State Chair Commission on Cancer

Submit your Letter to the Editor to Megan Campbell Smith at mcsmith@md-update.com

4 M.D. Update

Headlines

New KMA President Receives His Marching Orders

In addition to awareness of the issue of scope of practice, Jones is committed to public health issues such as childhood obesity, statewide restrictive smoking regulations, and promulgating HPV vaccinations. By Gil Dunn LOUISVILLE The Kentucky Medical Association’s new president Shawn, C. Jones, MD, FACS has a host of challenges ahead of him. The number one priority given to him by the KMA House of Delegates, says Dr. Jones, is medical liability reform. With the passage of the Patient Protection and Affordable Health Care Act, “cost containment in the form of medical liability exposure and premiums is still lacking,” asserts Jones. It is well known that the medical liability climate in states that border Kentucky, such as Indiana and West Virginia, are more favorable. Yet the Kentucky legislature fails to respond to one of the more severe causes of Kentucky’s physician retention and shortage problems.

Scope of Practice

Instead, the Kentucky legislature rushed into law Senate Bill 110. After only two weeks in committee, this law expands the scope of practice for optometrists, allowing them to perform a variety of surgical procedures on patient’s eyes with little more than 32 hours of additional training. Additionally, SB 110 gives the board of optometry oversight, independent of the KBML, on the scope of practice, privileges, and licensing of optometrist behavior in Kentucky. The KMA strongly disagreed with the legislatures’ and Governor Beshear’s decision to enact SB 110, which is seen by some as “a major expansion of scope of practice, enabling ancillary service providers the license to practice medicine without a medical degree,” says. Jones. “Healthcare professionals, such as nurse practitioners and pharmacists have a role and a right to participate in the total continuity of care. The physician, however, needs to be the leader of the healthcare team.” To carry this message forward into the public forum, the KMA developed M.D., I.D.: Know Who’s Treating You. Jones describes M.D., I.D. as the brain child of the KMA board of trustees and says it is designed to highlight the training of physi-

cians to the consumer patient. Leaders in the medical community have contacted their local media to advance public education on this important issue. Response, says Jones, has been favorable. “We are not saying we don’t need nurse practitioners,” Jones offers as an example. “I employ nurse practitioners in my office and they do a great job. The public, however, has a right to know that not everyone who

Other Legislative Objectives

Dealing with the ongoing physician shortage, particularly in rural family practice, is another priority for Jones. “The number of practicing physicians in Kentucky is decreasing,” he says. “Approximately 60% of Kentucky physicians are over 55 years old and retiring early. Couple that with lack of federal funding for medical schools commensurate with need, and we have a problem - especially for family practice in rural Kentucky.” Jones is committed to public health issues such as childhood obesity, statewide restrictive smoking regulations, and promulgating an HPV vaccine which he believes will virtually eliminate a major cause of cervical cancer in Kentucky women. Vaccinating children at an early age does not promote sexual promiscuity, he asserts. Jones has helped draft and implement a restrictive smoking law in his hometown of Paducah, Kentucky, and this experience motivates him to push Dr. Shawn C. Jones, otolaryngologist with Purchase legislators and local public health leadE.N.T. of Paducah, was installed as the 161st ers to adopt smoking bans similar to the president of the KMA at the annual meeting in ones in Louisville and Lexington. “The September. Also pictured is Evelyn Montgomery Surgeon General’s report that smoking is Jones, MD, dermatologist with WellsSprings Dermatology of Paducah. This is her second term as deleterious to one’s health is unequivocal,” says Jones, who believes that proFirst District delegate to the KMA House. tecting children, the elderly, and the calls himself a doctor has a medical degree.” working poor - all of whom have limited Still, Jones is convinced that Kentucky health choices – from second hand smoke is physicians are held in high esteem and an important priority for the state. respected by their patients. “We have a lot In 2010, the KMA Foundation received we can build on, but society has to decide a federal grant to increase rural Kentucky who they want to take care of them. In the physicians’ education and implementation of end, we are all patients,” he says. meaningful use of EHR. The Foundation’s During the KMA’s annual meeting this work has begun, says Jones, but Kentucky past September in Louisville, the national physicians are a long way from full converpresident of the AMA, Dr. Peter Carmel sion to EHR. This will be one of his goals: praised the M.D., I.D. program, giving it “Helping Kentucky physicians stay current the full support of the AMA. According with the changing healthcare environment to Jones, presidents of five medical societ- and technology through education. Without ies from surrounding states have expressed question, physicians who remain up-to-date interest in implementing M.D., I.D. in on current trends and technologies will give their states. better patient care.” ◆ M.D. Update 5

Dear Physician,

We at M.D. Update are continually humbled by the gracious reception we receive at your place of business. We never imagined we could grab the time and attention of over 22,000 physicians! Thank you for opening your doors to us. Over the past four years we have interviewed over 1000 Kentucky doctors and healthcare professionals. We have been inspired by your work to strive for ever greater outcomes, and we have come to view each issue of M.D. Update not just as a chance to connect socially, but a real opportunity to improve our health landscape. We asked, What can we do to

make M.D. Update more valuable to your practice?

We listened to your requests, and in 2012 we will improve our products and services to include:  A broader reach across the medical marketplace;  A deeper focus on the coordination of care;  Enhanced digital delivery options including a new tablet edition;  Doctor-to-Consumer healthcare marketing. Over the next few months, we will transition away from our complimentary subscription service and begin calling on your office to become paid subscribers of M.D. Update. We are thrilled whenever we hear how meaningful our work is to Kentucky’s medical community – and we are committed to continually striving for more. Thank you, Dear Physician, and let’s make this the best M.D. Update yet!

Gil Dunn

Megan Campbell Smith

Publisher

Editor-in-Chief

Published by Mentelle Media, LLC 921 Beasley Street, Suite 210 Lexington KY 40509 (859) 309-9939 phone & fax

finance

OK-ness As more and more baby-boomers approach retirement, we financial planners hear a common question: “Will I be okay?” Regardless of the age at which the process is undertaken, traditional financial planning typically involves, among other things, two steps: 1) deciding on a withdrawal rate that will preserve purchasing power, usually referred to as the maximum sustainable withdrawal rate (MWR) and 2) deciding on a savings rate that will enable the accumulation of enough money to provide the MWR for the remainder of one’s lifetime. Financial planners and researchers seem fixated on these variables as the most important unknowns to try to predict. A popular rule of thumb, or “Rule of Dumb”, as some would call it, sets the sustainable rate for everybody at 4% at the date of retirement and adjusts that amount upward each year for inflation. Dr. Wade Pfau suggests that, in projecting long-term sustainability for U.S. retirees, a 4% withdrawal rate cannot be considered “safe” in some circumstances. His recent article addressed the question of whether anyone can actually predict the sustainable withdrawal rate for new retirees. Pfau does point out that there are prob-

time when PE’s are high and dividend yields low? Okay, let’s suppose for a minute that you have estimated correctly the safe withdrawal rate and that by simply solving that BY Scott Neal equation, you have come up with the amount of money needed in your portfolio at the point of retirement to produce that rate of withdrawal for 30 years or more. Incidentally, this is the approach of nearly every online retirement planning tool. That’s all math and easy to conclude with the assumptions, good or bad, in place. Now the question arises as to the savings rate needed between now and retirement that will produce that sum of money. As we know all too well, that calculation assumes an amount of current savings, plus additions each year, plus a rate of return. The rates of return are usually based on historical averages. First of all, most historical averages used in that calculation consider some period of between

I hold the opinion that the typical financial planner adhering to the traditional financial planning process

places too much certainty on all of the rate variables... I would rather deal with what than with what “ought to be”.

“is”

lems associated with the traditional approach, not the least of which is the volatility of MWRs themselves. He points out that the MWR cannot be considered safe when the cyclically adjusted price-earnings ratio has experienced historical highs and dividend yields historical lows. He posits that these shifts in PE ratios and dividend yields are what cause the volatility. So stated, the problem is not the volatility of stock market returns but the luck of the draw of one’s birthday which sets the date of retirement for many. In other words, will I be unlucky enough to retire at a

30 and 80 years. The implication is that the next 30 years will mirror the last 30 to 80 and that all returns eventually return to their long run averages. Traditional planning holds that the portfolio question is properly addressed by setting an appropriate allocation between large asset classes such as stocks and bonds and that return follows risk, i.e. more risk equals a higher expected return. The devilish detail here is that risk is defined as volatility risk or the risk of not hitting the expected return. It is never defined as los-

ing money. I hold the opinion that the typical financial planner adhering to the traditional financial planning process places too much certainty on all of the rate variables: rate of withdrawal, rate of savings during the accumulation phase, and rate of withdrawal during the spending phase (retirement). I would rather deal with what “is” than with what “ought to be”. For those of you well-versed in statistics, the traditional approach may fall apart in several places. Two fundamental assumptions now seem to be wrong in modern portfolio management: 1) the assumption that the economy does not undergo structural changes, i.e. stationarity and 2) that the markets have no memory and that each period is identical and independently distributed. These have been invalidated by post-modern research; yet are still held sacred even among professionals who should know better. The truth of the matter is that hardly anybody lives on a fixed withdrawal rate throughout retirement, unless of course the entire portfolio has been turned into a fixed annuity supplemented by social security and the fixed withdrawal is mandated. That what is meant by “living on a fixed income.” If hardly anybody does it, then why has the sustainable withdrawal rate become the pursuit of so much research? Some suspicions are that it is because it is better for the asset manager / financial planner, rather than the retiree / client. What if one were to proclaim achieving and maintaining an acceptable living standard as the objective? Wouldn’t this year’s maximum sustainable living standard be a better answer to the ok-ness question? What if you could find ways to improve your current and future standard of living by changing some key planning parameters that are fully within your control? It is possible with modern methods that employ good economics. Scott Neal, CPA, CFP is President of D. Scott Neal, Inc., a fee-only financial planning and investment advisory firm. Send questions or comments to him at scott@dsneal.com or by calling 1-800-344-9098. ◆ M.D. Update 7

Law

Who Is the Doctor, Anyway? As more nurses, pharmacists, physical therapists, chiropractors and other allied health professionals obtain advanced degrees that confer the ability to use the title “doctor”, physicians should be concerned that losing control over the term “doctor”, a word that has identified physicians for centuries, will create confusion for consumers and lead to a loss of control over the practice of medicine. With a shortage of physicians nationally as well as in Kentucky, mid-level practitioners are becoming the gatekeepers for health care. Mid-level practitioners now make important medical decisions about diagnosis and access to care. In Kentucky, the Kentucky Board of Medical Licensure (KBML) has taken an active role regulating the practice of certain allied health professions. Professions that have their own licensing authority, however, have the ability to broaden the scope of practice of their profession and determine what title may be used. The tensions between the professions may culminate in who gets to use the term “doctor”. The KBML has little control over Advanced Registered Nurse Practitioners (ARNP). ARNPs are regulated by the Kentucky Board of Nursing, which has the statutory authority to regulate the nursing profession. An ARNP’s scope of practice is essentially defined by the specialty board certification earned by the nurse. Every ARNP is required to have a collaboration agreement with a physician for prescribing medication, but not to practice as an ARNP. The KBML has asserted control over ARNP’s by issuing specific requirements for the physicians who serve as the collaborators. Detailed requirements for these agreements vary based upon whether the agreement covers controlled substances or nonscheduled legend drugs. Additionally, the KBML will only allow physicians to enter into two collaborative agreements and has issued a very detailed Board Opinion establishing the standards of prevailing practice for physicians collaborating with an ARNP. Other than the requirement for a collaborative agreement, an ARNP, however, 8 M.D. Update

may function independent of a physician and is entitled to bill patients for services. Twenty-three states allow nurse practitioners to practice without BY Lisa English Hikle physician supervision or collaboration. While ARNPs are required to obtain a masters degree and pass a certification examination given by a specialty board that is recognized by the Kentucky Board of Nursing, ARNP’s are not entitled to use the term “doctor”. When an ARNP earns a doctorate, the ARNP will have a doctorate in nursing along with the authority to use the title “doctor of nursing”. As a recent New York Times article reports, last year 153 nursing schools awarded doctor of nursing practice degrees to 7037 nurses and is projected to grow along with more nurses using the title doctor. Physician Assistants (PA), on the other hand, are regulated by the KBML, which has issued very specific supervision requirements that are more detailed than the collaborative agreements for ARNPs. In 2010, the Kentucky Legislature enacted a statute authorizing licensure of PAs for the first

time. PAs, however are regulated by the KBML, not by a profession specific board. The PA’s licensure statute limits not just a PA’s scope of practice, but also a PA’s ability to bill for his or her services independently of a physician. The statute specifically prohibits a PA from prescribing medications for a patient, requires a physician signature for medical records, and requires the active and continuous supervision of a physician. In fact, a PA may not practice in a location separate from a physician until the PA has 18 months experience and then the PA must apply for permission from the KBML to practice in a location separate from a supervising physician. In addition, a physician supervising a PA must complete a very detailed application that sets forth the scope of practice of the PA and the type of supervision that will be provided. By comparison, nurse practitioners have much more autonomy than PAs in Kentucky. Like nurse practitioners, physical therapists have their own licensing statute, are regulated by their own board, and function autonomously of the KBML. The physical therapy statute also makes clear that a physician’s order is not necessary to provide physical therapy to a patient. While there has been some dispute concerning whether a physician may perform physical therapy for patients, Kentucky’s Supreme Court resolved this dispute and ruled that

The tensions between the

professions may culminate in who gets to use the term “doctor”.

physicians could perform physical therapy. Currently, physical therapists are required to complete bachelor degrees and pass the profession’s national examination. By 2015, the profession will require physical therapists to have doctorates to take the certification exam. Like nurses, physical therapists who earn a doctorate degree will be entitled to report their credentials as a doctorate in physical therapy with the ability to use the title “doctor”. When it has been appointed by the Legislature to serve as the regulatory board for professions like acupuncture, athletic trainers, and surgical assistants, the KBML has issued regulations that create very specific requirements for these professionals and define their scope of practice to require physician involvement. For example, acupuncturists are required to develop written

plans for consultation to maintain relationships with two physicians, and to inquire of potential patients whether they have certain dangerous conditions. If a patient reports one of the specified conditions, then the acupuncturist is required to consult with the patient’s treating physician before acupuncture is performed. As patients increasingly seek health care from mid-level practitioners, use of the title “doctor” promises to become more common as ARNPs and physical therapists will be entitled to use “doctor” just like chiropractors and pharmacists. In a certain respect, use of the educational credential and title “doctor” is nothing new. But, as the gatekeeper to medical services becomes not just physicians but also ARNPs, physical therapists, and possibly PAs, the issues presented by scope of practice between these

professions will become increasingly complicated and sure to result in confusion for the consumer about who really is the doctor. 1 Harris, Gardner, “When the Nurse Wants to Be Called ‘Doctor’ “New York Times, October 1, 2011. 2 KRS 311.844 3 Dubin Orthopaedic Center PSC v. Commonwealth of Kentucky, State Board of Physical Therapy. 294 S.W.3d 421 (Ky. 2009). 4 KRS 311.673, 311.680, and 201 KAR 9:460

Lisa English Hinkle is a Partner of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Hinkle concentrates her practice area in health care law and is located in the firm’s Lexington office. She can be reached at lhinkle@mmlk. com or at (859) 231-8780. This article is intended as a summary of newly enacted federal law and does not constitute legal advice. ◆

M.D. Update 9

Insurance

Do You Need a Prescription for Long-term Care Protection? Long-term care insurance has been around since the 1980s and most people are somewhat familiar with the product. The question becomes, “Do you need the protection?” There is no simple answer; different circumstances call for different solutions. Long-term care insurance is designed to help pay the cost of providing assistance for those who can no longer perform normal daily activities. There are four topics to consider when reviewing the need: provide protection for our parents, age gap between you and your spouse, your healthy life style, and the want for wealth preservation. Many of us who have living parents may find it necessary to help with personal care. In our grandparent’s day, families weren’t dispersed across the country and family members often took care of relatives in need. That’s not always the case today; sometimes circumstances do not allow children to perform the care for the parents. In these situations, the only option may be a paid caregiver, assisted living facilities, or moving in with us. These possibilities can significantly affect our careers, retirement planning as well as college education for our children. Medicare programs do pay limited benefits for rehabilitation and recovery at a skilled nursing facility immediately following a hospital stay, but won’t pay for the slow decline in daily activities. Medicare does not pay for custodial care to support issues with dressing, bathing or pre-primary meals. In many marriages there is an age gap between the spouses. The need for longterm care by an older spouse could cause significant problems among the children and the healthy spouse. In this situation, long-term care cost could deplete assets that the younger spouse may need for children’s education or normal living expense for the next 10, 20, 30, or even 40 years. Also, for those in second marriages there is a common misconception Medicaid and eligibility determined by evaluating a person’s assets and income. Many second marriage couples believe that if a pre-nuptial agreement is in place, which separates the couple’s funds, they will not have to spend down 10 M.D. Update

their combined assets before qualifying for welfare. The truth be told, pre-nuptial agreements do not protect a couple’s assets from Medicaid’s spend down requirements. BY Calvin R. Rasey Did you ever stop to think that good health at retirement is going to cost you more money? The Center for Retirement Research at Boston College reflects a couple in good health at age 65 in 2009 can expect to pay on average $260,000 for out of pocket health care expenses. While a couple with at least one chronic disease will end up spending on average $40,000 less. Boston College goes on to explain that: “First; people in good health can expect to live significantly longer. At age 80, people in healthy households have a remaining life expectancy that is 29% longer than people in unhealthy households, and, therefore, are at risk of incurring health care costs over more years. Second, many of those currently free of any chronic disease will succumb to one or more such diseases. For example, our simulated individuals who are free of any chronic diseases at age 80 can expect to spend one-third of their remaining life suffering from one or more diseases. Third, people in healthy households face an even higher lifetime risk of requiring nursing home care than those who are not healthy, reflecting their greater risk of surviving to advanced old age, when the risk of requiring such care is highest.” So if you’re around longer, chances are you’re going to run into more medical costs not to mention a higher risk for nursing home care. For a significant amount of physician’s wealth, preservation has become an area of concern due to the volatile stock market and small yields seen on relatively safe investments. Physicians that once thought they could pay for care out-of-pocket may not

be able to generate enough income from their portfolio without dipping into the principle. If one is conservative by nature or is at the point in their life that investment risk needs to be reduced or is unnecessary longterm care insurance can be the right match. Transferring the risk of the ever increasing long-term care to an insurance company would not be a waste of money, but a way to preserve wealth. In essence, long term care insurance is a good option for many Americans, but not all. One of the main objectives of long-term care insurance is it is designed to protect assets, so if there are not assets to protect then you shouldn’t purchase long-term care insurance. You must weigh the pros and cons before jumping into this decision, but more often than not it is a wise choice to get covered. Be aware that is order to be eligible for your claim, your doctor must certify that you are not able to perform two or more activities of daily living functions for a period of three months or more. These include, but are not limited to: bathing, eating, dressing, continence, transferring and toileting or suffer from a cognitive impairment such as dementia. ◆ Securities Offered Through Securities America, INC.*Member FINRA/ SIPC • Calvin R. Rasey • Registered Representative. Advisory Services offered through Securities America Advisor’s, INC.• A registered Investment Advisor·Calvin R. Rasey • Investment Advisor Representative. Physicians Financial Services II, LLC and Securities America Companies are NOT UNDER Common Ownership. Representatives of Securities America do not offer tax or legal advice. The opinions and forecasts expressed are those of Calvin R. Rasey, are general in nature and cannot be guaranteed. Securities America and its representatives do not provide legal advice. For questions about a specific situation please consult your legal advisor.

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M.D. Update 11

Practical Insight  ENT-hns

ENT/DMD Hones Head and Neck Cancer Expertise

Wayne B. Colin DMD, MD brings microvascular reconstructive surgery expertise to Lexington Clinic.

Dr. Wayne B. Colin, like other otolaryngologists, treats cancers of the head and neck, however, his unusual training and background makes his practice unique. He began his career as a dentist, transitioned into oral and maxillofacial surgery, and then into ear, nose and throat (ENT) surgery before completing a one-year fellowship in microvascular reconstructive surgery. “If you look at my background – dentist, facial bone doctor, and soft tissue doctor patching cancer wounds – I have experience and a broad expertise that is highly unusual,” says Colin. As a result, Colin can care for patients whose needs range from trivial oral issues to life threatening and devastating cancers. Colin has been interested in the practice of medicine since he was a child. He spent two years on academic staff at Harvard University and Massachusetts General Hospital in Boston. During his fellowship year, he had a clinical appointment to Barnes Hospital & Washington University in St. Louis. He also served on academic staff for more than a year at University of Tennessee. Now, after 15 years of experience, Colin is a three-time university doctor in private practice and provides universitylevel care in a clinic setting.

A Full Array of Reconstruction

It is the combination of dental, surgical, and private practice experience that helps Colin treat patients more effectively. Many conditions which would traditionally require multiple physicians, for example, those who could remove cancer followed by those who could provide reconstruction, can now be managed under his exclusive care. Bone and soft tissue manipulation of the head and neck region are commonly performed by different specialties. “Most 12 M.D. Update

Kirk Schlea

By Nicole V. Candler

Dr. Wayne B. Colin specializes in the reconstruction of cancer wounds in the head and neck and is boardcertified in oral and maxillofacial surgery and otolaryngology head and neck surgery.

people can understand that ENTs, oral surgeons, and plastic surgeons are experts in their own fields, but often these practices don’t cross pollinate,” says Colin. Oral surgeons tend to focus on teeth and bones, while ENTs perform soft tissue procedures, but they do not have the same education regarding the teeth, the occlusion, and the jaw joint. “My specialty (ENT) is said to be from ‘dura to pleura’,” he says. “I focus on the head and neck, which literally means everything that is between the lining of the brain down to

the lung, including reconstruction needs.” He will frequently work with neurosurgery, thoracic surgery or vascular surgery depending on the requirements of the case. With great frequency he will work with the Moh’s dermatological surgeon who will remove a skin cancer, after which, Colin will close the wound, particularly wounds of the nose, scalp, cheek or ear. The artful skills that Colin employs in many cancer wound reconstructions come from his training and experience in microvascular surgery. “The concept of microvas-

Surgical images courtesy of Wayne B. Colin, DMD, MD

Nose Surgery Offers a Practical Example of the Ladder of Reconstruction 1. After removal of basal cell skin cancer of the nose. 2. After initial procedure to repair nasal defect – forehead flap. 3. Three months after inset of flap for nasal reconstruction. cular surgery,” says Colin, “is easy enough to understand, but its application – the artistic part – requires insight, experience and a keen understanding of form and function.” Microvascular techniques involve the removal of an artery, vein, and a patch of overlying skin/fat and bone, for example – from the forearm. The patch is then connected elsewhere, such as in the neck, to appropriately sized vessels using micro stitches, micro instruments, and a microscope. The opposite end of the vein and artery are then reconnected to the damaged or diseased area, such as the eye socket, the face, the mouth or the throat. The graft heals as would any incision, and because of the robust blood supply, these procedures are very useful in reconstructions of the head and neck, especially areas that have had prior trauma, infection or radiation.

The Ladder of Reconstruction

When determining how to reconstruct a cancer wound, Colin considers the reconstructive ladder. From simple to compli-

cated, the reconstructive ladder determines from where to retrieve the reconstructive tissue and to what extent reconstruction is required. On the simple end of the reconstruction ladder, the procedure is treated like a common wound, and it heals on its own, aided by wound care. The procedure rises on the ladder when the tumor and affected area is resected; the edges pulled together and closed with stitches. Further up the ladder are local, then regional tissue flaps and more complicated procedures requiring transplantation of vessels, skin, bone, or muscle from a distant site. Determining a patient’s position on the ladder requires great expertise. “In some situations, in part because of social, neurological, or other reasons, a complicated treatment is not what is best for the patient,” says Colin. For example, Colin was recently visited by an elderly nursing home patient with cancer on her nose. He determined that reconstruction would not be in her best

interest – being that she was frail and confused. Moreover, she could not hold still to tolerate radiation. Her procedure was done to control her pain and eradicate her cancer. While no surgical reconstruction was offered, she was a candidate for a prosthesis. This is in contrast to a younger woman who had undergone jaw resection for benign aggressive disease, who had a successful jaw graft and sensory nerve reconstruction. “Deciding whether or not to offer an operation and whether to be as aggressive as one might, including a reconstructive surgery, is determined by patient, family, level of insight, medical co-morbidities and disease characteristics – nothing is cookbook,” says Colin. Colin’s broad medical background and integrated approach to cancer treatment are assets to the medical community. His expertise in reconstructing cancer wounds means that “unless there is a very rare and specific reason, I don’t turn cases away or send them to a university practice because I have the skills to help them here.” ◆ M.D. Update 13

14 M.D. Update

BURDEN & Opportunity: Trends in Oncology Care

{Part One}

Cover story

Drs. Vijay Raghavan and Subhash Sheth are medical oncologists with Cancer and Blood Specialists, part of OBFCC Louisville South End. With the diagnostic, treatment, and prevention services of Sts. Mary & Elizabeth Hospital and the radiation oncology services of Louisville Radiation Oncology, OBFCC Louisville South End is the only comprehensive cancer care campus serving south Louisville, Bullitt County, and Fort Knox.

High Incidence & the Complexity of Care

OBFCC Louisville South End is devoted to serving an underserved population By Jennifer S. Newton, photos by Kirk Schlea

“We love this area. This is the part of town where we started our practice, and we are dedicated to serving this part of the community,” says board-certified medical oncologist Subhash Sheth, MD, of his community-based oncology practice in Louisville’s South End. Sheth’s practice, Cancer and Blood Specialists, is one of the partners in Jewish Hospital & St. Mary’s HealthCare’s (JHSMH) multidisciplinary cancer program, Owsley Brown Frazier Cancer Center (OBFCC). OBFCC’s Louisville South End campus integrates the medical oncology services of Cancer and Blood Specialists with the diagnostic, treatment and prevention services of Sts. Mary & Elizabeth Hospital (SMEH), the Women’s Center at SMEH, and Louisville Radiation Oncology. The result is a comprehensive cancer care campus serving patients from throughout

the city but primarily focusing on south Louisville, Bullitt County, and Fort Knox. Accredited by the American College of Surgeons’ Commission on Cancer (CoC), OBFCC is the only cancer care provider in Louisville’s South End. While others were vacating the area in favor of more profitable locations on Louisville’s east side, providers like Cancer and Blood Specialists remained committed to the community and teamed up with JHSMH to meet the needs of an underserved population. According to Sheth, this area has one of the highest incidences of cancer in Louisville, especially lung, head and neck, colon, and breast cancers. He attributes the high concentration to poor access to screening tools and high percentages of tobacco and alcohol use.

Complexity of Care

Determining and executing the right course of treatment is a multifaceted team effort, including medical oncologists, radiation oncologists, surgeons, radiation therapists, pathologists, interventional radiologists and pharmacy technicians. The group holds tumor boards once or twice a month to collaborate on complex cases. By working in tandem, they can recommend a customized course of treatment based on the type and stage of cancer, its location, the patient’s overall health, and other mitigating factors. For patients, the diagnosis and subsequent treatment can be daunting. Being part of an oncology campus means, “Our patients do not need to go anywhere else for their treatment,” says Sheth. Imaging studies and lab tests used in diagnosis, staging and monitoring are done with equipment, such as a PET scanner located at Cancer and Blood Specialists or digital mammography October 2011 15

cover story

just a block away at the Women’s Center at SMEH. These are the only such equipment in the South End. Chemotherapy and other infusions are administered at the medical oncology offices and are dispensed by a pharmacy tech onsite. “Our practice would be incomplete without an excellent radiation center, which is right next door to us,” says Sheth. Louisville Radiation Oncology offers stateof-the-art image guided radiation therapy (IGRT) and intensity modulated radiation therapy (IMRT), which allow for more precisely targeted treatment to tumors and less collateral damage to normal structures. “In conjunction with the radiation oncologist, we get stereotactic radiation therapy and brachytherapy,” says Vijay Raghavan, MD, board-certified medical oncologist also with Cancer and Blood Specialists. Interventional radiologists located at SMEH add radiofrequency ablation (RFA), chemobolization, and interventional vascular procedures to the complement of services. In recent years, breast cancer has become focal point for the OBFCC Louisville South End due to a gap in diagnostic services for women, leading to the creation of the Women’s Center at SMEH. “Standard mammography has been supplanted by digital mammography because of the better control of the whole process: better images, better archival images, and the radiologist can better compare one study to another,” says Ragahavan. In addition to digital mammography, services include breast MRI, stereotactic breast biopsy and a dedicated breast radiologist. While screening is essential to saving lives by detecting cancer early, the OBFCC takes their approach a step farther – genetic testing for hereditary predisposition to cancer. Integrating a genetic testing component into the multimodality model helps evaluate other factors in cancer and focus on prevention. [See sidebar for more information on genetic testing.]

Benefits of Integrated Services

Shawn Glisson, MD, cancer program director for OBFCC, concurs that the integra16 M.D. Update

tion of hospital cancer programs and physician practices provides for more effective overall care. Regulatory bodies such as the CoC require “that your treatment centers have the full compendium of services from the time of screening, to the time of diagnosis, to the time of treatment, to the time of cancer survivorship and monitoring,” says Glisson. “What a program is really about is that all these different components within the chain are coordinated.” The OBFCC umbrella provides its partners with an excellent research structure and a teaching-based hospital program, along with centralized services such as pharmacy, cancer services management, participation in the National Cancer Data Base, and the guidance of high accreditation standards and national quality metrics. The next step for OBFCC is to unify additional facilities, such as Jewish Hospital Shelbyville, and physician groups under their system. OBFCC is in the process of opening an office at Jewish Hospital Medical Center South to service the Shepherdsville and surrounding Bullitt County area, which currently has no hematology/oncology center. “We hope to expand this program throughout the Commonwealth with our new partners and Lexington,” says Glisson. ◆

Dr. Shawn Glisson, cancer program director for OBFCC, makes sure that all of the providers and services are well coordinated and meeting the needs of the population.

Dr. Amir Harandi is a medical oncologist and genetics specialist with OBFCC who provides testing for underlying genetic syndromes and counseling for the prevention of cancer.

Genetic Testing Saves Lives “A significant percentage of cancers are due to hereditary factors,” says medical oncologist and genetics specialist Amir Harandi, MD. “As part of our comprehensive cancer program, it is important to counsel patients and identify underlying genetic syndromes to help prevent cancer.” The two main hereditary syndromes Harandi tests for are breast and ovarian cancer, from BRCA1 and BRCA2 mutations, and Lynch syndrome for colon cancer. Five to 10 percent of breast cancers are hereditary, and of those, a significant proportion is due to mutations BRCA1 and BRCA2. A recent study published in the journal, Genetics in Medicine, showed that six percent of the mammography population had a high enough risk to be referred for

consideration of BRCA1/2 testing. Harandi explains, “The threshold for testing a BRCA mutation is when one’s risk is close to exceeding five percent,” which is measured by a computer model. The risk of breast cancer due to mutation at age 50 is 50 percent and is 87 percent by age 70. The risk for ovarian cancer by age 70 is 44 percent. The options for reducing breast cancer risk are the addition of MRI to mammography and prophylactic mastectomy. Studies have shown that prophylactic bilateral mastectomy reduces the incidence of breast cancer by 90 percent. However, substituting prophylactic mastectomy with the combination of MRI plus mammography seems to offer comparable survival, according to a 2010 study published in the Journal of Clinical Oncology. Removing the ovaries by age 40 can also greatly reduce the incidence of breast and ovarian cancer. BRCA is a tumor suppressor gene and is inherited in autosomal dominant fashion. In addition to breast and ovarian cancer, BRCA1 can cause cervical, uterine, pancreas, gastric, and prostate cancers. BRCA2 can cause melanoma, gallbladder, bile duct, prostate, pancreas, and stomach cancers. Lynch Syndrome

Due to mutations in a series of genes, including MLH1, MSH2, MSH6, PMS2, and EpCAM, Lynch syndrome eliminates our ability to repair DNA damage. It is also inherited in autosomal dominant fashion and results in an exceedingly high risk of colon and uterine cancer, increasing colorectal cancer risk to 25 percent by age 50 and 80 percent by age 70; uterine cancer to 20 percent by age

50 and 70 percent by age 70. Other cancers caused by Lynch syndrome include gastric, ovarian, small bowel, biliary, ureter, renal pelvis, pancreas, and brain. According to Harandi, Lynch syndrome has a higher concentration

in Kentucky. “The importance of picking this up is because colon and uterine cancer are two very preventable cancers,” says Harandi. In Lynch syndrome, colon polyps become cancerous at an accelerated rate of one to three years as opposed to five to ten years in the unaffected population. Screening with frequent colonoscopies every one-two years can greatly reduce colorectal cancer risk and mortality rates. In addition, removal of the uterus and ovaries after childbearing years can dramatically reduce the risk of these cancers. One of every 35 patients with colorectal cancer has Lynch Syndrome, and studies have shown that each patient diagnosed as a carrier has at least three relatives with Lynch Syndrome... “Not only are we testing patients in the affected population, but we are willing to see patients in the unaffected population, who have a strong family history and are potential carriers of this syndrome,” says Harandi. ◆

October 2011 17

BURDEN & Opportunity: Trends in Oncology Care

The Physical and Emotional Needs of Patients

Norton Cancer Institute - Downtown provides for the unique treatment-related needs of cancer patients and their families By Jennifer S. Newton

18 M.D. Update

{Part Two}

“More like an art museum than a medical center,” is how Aaron Spalding, MD, PhD, adult and pediatric radiation oncologist, describes the new Norton Cancer Institute – Downtown. Combining the wellness attributes of evidence-based design principles with the most advanced technology and a cooperative of medical professionals, the institute delivers all encompassing care to the region’s cancer and tumor patients with a “park once” philosophy. Located at the corner of Broadway and Floyd streets in downtown Louisville, the facility is LEED (Leadership in Energy and Environmental Design) certified as a “green” facility and is connected by pedway to the rest of the Norton Healthcare downtown campus. The design employs color, light, pattern and texture to create a warm and healing environment to meet the medical and emotional needs of adults and children with malignant and non-malignant tumors and their conditions. “When we built this building, our number one priority was not moving the patient,” says neurosurgeon Todd Vitaz, MD. Consider the number of medical professionals involved in a cancer patient’s care: surgeon, medical oncologist, radiation oncologist, rehabilitation specialist, psychiatrist, social worker, etc. Then consider that the patient and their family could access all these services by essentially parking their car once, in one location, without multiple trips to various providers, thereby

Neurosurgery oncologist Todd Vitaz, MD, adult and pediatric radiation oncologist Aaron Spalding, MD, PhD, and radiation oncologist Michael J. Hahl, MD collaborate in the multidisciplinary clinics at Norton Cancer Institute - Downtown.

lessening the anxiety of an already stressful situation. That is the vision that providers worked in tandem with architects to make possible. “We are actually the only center in America designed to simultaneously address the psychosocial and medical needs of pediatric and adult patients,” says Spalding. The first floor of the Norton Cancer Institute – Downtown houses its Radiation Center. The second floor is home to the Multidisciplinary Center. Reflective of the overall design, the clinics and protocols housed within the building focus on providing optimum diagnostic care and treatment, designed so that patients and families are an integral part of the caregiving team. According to Vitaz, “We’ve streamlined care so that everyone is on the same page. We discuss the patients while the patients are in front of us. We look at the films together and go through options.” A nurse navigator helps coordinate the overall care plan.

Radiation Center

Radiation oncologist Michael J. Hahl, MD, has always been interested in radiology, but says, “While the technology is critical, it’s about the patients for me.” The institute

Pediatric Care

Spalding modeled the center’s integrated pediatric anesthesia suite after the pediatric radiology center at St. Jude Children’s Research Hospital in Memphis, where he completed a pediatric radiation oncology fellowship. He also holds a PhD in pharmacology and experimental cancer therapeutics and provides research expertise to the program. He points out that cancer centers that provide pediatric care are rare. Childhood cancers have a much lower incidence than adult cancers and most are curable, but they are biologically different and require special consideration for long-term consequences. “A big emphasis in pediatric cancers is dealing with the side effects of having the disease as well as the treatment,” says Spalding. “What problems are they at risk for because of their treatment

versus what are just normal adult problems for them?” Spalding cites a patient that had a pelvic tumor at age 11 and underwent surgery, chemotherapy, and radiation. Now in her mid-20s, she was experiencing pain and came to the clinic worried the cancer had returned. “Is this something related to her treatment or is she just a normal 25-year-old woman who runs too much? In the setting of being an adult now, this previous history influences which tests she needs. So there are medical and mental aspects, and the integration between the two,” says Spalding, emphasizing that these type of survivorship issues are addressed by the center’s Survivorship Clinic.

brain tumors, he ensures his patients get the best possible treatment for their situation. As with the other illnesses treated by the institute, the Sarcoma Clinic and the Lung Cancer Clinic provide a team of disease-specific physicians in the convenience of one location. With one appointment, patients can have their needs addressed by all the specialists consulting on their case. The Survivorship Clinic provides guidance on the health consequences of therapy, screennorton Healthcare

treats just about any type of malignancy that warrants radiation, as well as nonmalignant tumors such as pituitary adenomas or meningiomas. “On top of that, our new technology allows us to treat previously untreatable conditions,” says Hahl, including trigeminal neuralgia, movement disorders such as Parkinson’s, and obsessive-compulsive disorder by utilizing the radiation accelerator for target lesioning in the brain. The planning stage of radiation is essential to pinpointing targets and avoiding critical healthy tissues. High-speed CT imagery along with specialized equipment allows physicians to identify and track tumors in real time and space to accurately target treatment. Norton Cancer Institute’s image guided radiation therapy (IGRT) is unique in that it allows physicians to dynamically track a tumor and to treat it at the same time. The center’s linear accelerator and stereotactic radiosurgery system also deliver intensity modulated radiation therapy (IMRT) employing micro multileaf collimators. “By doing that, you can intensify treatment to the malignant areas and diminish treatment to the normal structures,” says Hahl.

Multidisciplinary Center

The second floor of the building is home to the center’s multidisciplinary clinics: Brain Tumor Center, Sarcoma Clinic, Survivorship Clinic, Lung Cancer Clinic and patient clinical trials. The concept for the center was born out of the pioneering collaboration of Vitaz and his colleagues in multidisciplinary brain tumor treatment. Vitaz, who did a fellowship in neurosurgical oncology at Memorial Sloan-Kettering Cancer Center, envisioned a local center that mimicked the big cancer centers. Begun as a cooperative between Norton Neuroscience Institute and Norton Cancer Institute, the Brain Tumor Center provides a team of fellowship-trained specialists and seeks to minimize the anxiety of an already stressful diagnosis. Brain tumors are categorized as aggressive and nonaggressive, rather than malignant and non-malignant, because both primary and metastatic brain tumors can have devastating effects. “With brain surgery the goal is quality of life,” says Vitaz. For example, he uses techniques such as awake craniotomy to maximize the amount of tumor resected without unnecessarily compromising function. But Vitaz recognizes surgery is not always the best treatment option for each patient. By collaborating with oncology specialists who also have an interest in

Dr. Spalding says the design of the new Norton Cancer Institute - Downtown as "more like an art museum than a medical center." The facility earned a prestigious LEED Gold certification.

ing for other cancers, counseling and more. Integrating medical care with clinical research allows the institute to offer novel therapies to patients who have few proven treatment options – especially for brain tumors. Most of the center’s clinical trials are national consortium studies; however they also participate in private pharmaceutical studies and industry-sponsored studies. According to Vitaz, mind power is their greatest technology. “I think the ability to have all of us together at the same time while taking care of patients really goes above and beyond what anyone else is doing. It really benefits the patient,” he says. And while aggressive treatment is part of their philosophy, “The goal isn’t just to get rid of cancer, it’s to give patients full, happy, and healthy lives,” adds Spalding. ◆ October 2011 19

BURDEN & Opportunity: Trends in Oncology Care

{Part Three} Kirk Schlea

Technological Advancements & Improved Survivals

Microwave ablation aides in dramatically improved liver tumor outcomes at Lexington clinic By Megan C. Smith Lexington Clinic surgical oncologists Richard C. Montgomery, MD, FACS (above) and William W. Walton, MD, FACS (Right) employ faster, more efficacious microwave ablation technology in the resection of primary liver tumors and shrinkage of metastatic liver tumors as part of a multimodal approach to cancer care.

20 M.D. Update

While liver cancers are becoming increasingly common in the Commonwealth, surgical oncologists have a new tool that can dramatically improve the safety and efficiency of both primary and metastatic liver tumor surgeries. Microwave ablation (MWA) for hepatic tumors is gaining ground in the US, and two Lexington Clinic (LC) surgical oncologists are employing the technology to attain curative results for previously untreatable cancers. In use at LC for almost one year now, MWA â&#x20AC;&#x153;has made liver resection more streamlined, more effective,â&#x20AC;? says Richard C. Montgomery, MD, FACS, Lexington Clinic surgical oncologist. The efficacy of MWA comes from the ability to place the probe directly inside the tumor and heat the tumor from the inside-out using microwave technology that elevates tissue temperature by excitLEXINGTON

ing the water molecules within. The resulting heat destroys tumors by coagulation necrosis. Compared to radiofrequency ablation (RFA), the high temperature necessary to cause cellular death is delivered faster and with less heat loss via transference through adjacent vessels. It is also more efficacious by concentrating heat in a smaller area, thereby sparing noncancer cells. In short, MWA does a better job in a shorter period of time than traditional RFA, resulting in improved outcomes with shorter recovery. While MWA is becoming well known as a safe and effective way to treat unresectable liver tumors, Montgomery points out that the benefits of MWA make it a useful tool in the resection of liver tumors, thereby making resection attainable for more patients. Before MWA, many liver tumors could not be resected because of high bleed-

Resection is still the only chance for a cure. If you can resect and you have the right type of disease with a small number of metastatic lesions and you can do a proper anatomic resection, you get about 35% survival. – Dr. Richard Montgomery

Improved Survivals

“In the distant past, the prognosis was poor if you had a metastatis to your liver,” says William W. Walton, MD, FACS, who has provided general and oncology surgery at LC for over 34 years. “You were unable to do anything except palliative chemotherapy. Now, in the right situation, sometimes we can resect the spread and actually cure the cancer.” Walton explains that these cures have been shown in colon cancer and some breast cancer metastases. Primary cancers, he cautions, are being selected very carefully because of the high bleeding risk. The microwave ablation system has enabled

surgery without as much blood loss. The historical survival for people who have unresectable metastatic cancer of any type is usually less than one year. Walton and Montgomery find that the fact that they have been able to treat this disease and get patients back to a no evidence of disease (NED) state intuitively translates into better disease-free survival. While overall survival statistics are not available, the hope is that attaining NED states will eventually

translate into improved long-term survivals throughout the community. “Resection is still the only chance for a cure,” says Montgomery. “If you can resect and you have the right type of disease with a small number of metastatic lesions and you can do a proper anatomic resection, you get about 35% survival.” Additionally, MWA significantly extends short-term survival while providing palliative benefits, including pain relief and quality of life improvements that come along with getting people back to their normal lives. Liver resection for either primary or metastatic cancers is appropriate only for limited disease. When there is not enough residual liver, cautions Montgomery, or there is involvement of both lobes or multiple sites, the best alternative is MWA. Very often he is able to perform liver resection and MWA laproscopically, resulting in faster recovery and return to normal activity for the patient. For unresectable cancers including metastatic cancers of the colon and breast, Montgomery will ablate lesions with MWA under ultrasound monitoring. With chemotherapy upfront, he says, survival is a good. “Lexington Clinic has been providing tertiary care for liver surgery for more than 10 years,” says Montgomery, “utilizing a multimodality approach to the treatment of cancer.” This approach includes, for example, the expertise of gastrointestinal specialists to employ endoscopic retrograde cholangiopancreatography (ERCP) to alleviate and palliate liver tumor. ◆ Lexington Clinic

ing risk, but MWA mitigates that risk by sealing vessels before cutting through them. Montgomery explains that he performs MWA before liver resection, laying a margin that reduces blood loss before performing a formal liver resection. Resection offers the only chance for a cure for liver cancer. Montgomery, who studied liver disease therapies during his fellowship at Fox Chase Cancer Center in Philadelphia, reports that he is currently achieving better outcomes with MWA in liver resection than was previously possible. Historic survival for unresectable liver cancer is less than one year without any treatment, and long-term survival data following ablation is still in development. Montgomery points to papers such as “Safety and Efficacy of Microwave Ablation of Hepatic Tumors: A Prospective Review of a 5-Year Experience” in the Annals of Surgical Oncology (Martin, Robert C. G., et. al., January 2009) that show that MWA can be done with good efficacy and good safety and with low complication and low recurrence rates.

October 2011 21

BURDEN & Opportunity: Trends in Oncology Care

{Part Four}

Compassionate, Patient Focused Care Pikeville Medical Center provides multidisciplinary cancer care tailored to the needs of Eastern Kentucky. PIKEVILLE Cancer care in eastern Kentucky has developed rapidly in the past few years to incorporate a multidisciplinary approach including state-of-the art treatment modalities. Pikeville Medical Center (PMC) has been at the forefront, customizing the care provided to meet the needs of the population. Investing ten million dollars in stateof-the art equipment like the Varian Trilogy RapidArc linear accelerators, and recruiting the most qualified physicians, PMC is aggressively tackling the issue. Tamara Musgrave, MD, medical director of the Leonard Lawson Cancer Center (LLCC) at PMC, believes recruiting and retaining board certified, experienced colleagues makes a significant difference in the cancer care provided to patients in the region. After a decade in private practice, in 2008 Musgrave joined Drs. Raghuram Modur and Vijaya Puram, radiation and medical oncologists respectively, at the cancer center. CEO Walter E. May, the PMC Board of Directors and the staff of the LLCC shared a vision of providing multidisciplinary care, prevention, early detection, diagnosis, treatment, research, and supportive services to patients from the 22 M.D. Update

surrounding areas. “Part of the growth and expansion of the Leonard Lawson Cancer Center,” says Musgrave, “is our belief that we must bring the care to the patient.” In recent years, the LLCC staff has grown to include other medical oncologists including Dr. Vikki Morgan, Dr. Lillian Thomas, Dr. Holly Gallion and Dr. Bharat Jenigiri. Dr. Gallion is a specialist in gynecologic oncology, and Dr. Jenigiri specializes in palliative care. Genetics counseling is also offered at the LLCC. Numerous clinical research trials have been opened in prostate, breast and lung cancer, drug therapy, and gynecologic oncology. Musgrave identifies the opening of clinical trials in Pikeville as essential to meet the cancer needs of the region. The development of epidemiological studies, she says, features prominently in the next phase of growth at LLCC.

Dr. Holly Gallion, gynecologic oncologist, and Dr. Tamara Musgrave, medical oncologist and infectious disease specialist, bring advanced multidisciplinary cancer care and clinical research trials to the area.

Expanding Access to Care

PMC’s facilities and providers have opened access to many patients who previously might have travelled to distant cities for treatment. Radiation oncologist John Simmons, DO, joined PMC in 2007 and was instrumental in bringing the latest radiation equipment and technical expertise to the region. He and Dr. Modur utilize two Varian Trilogy RapidArc linear accelerators, and are able to deliver radiation in a fast and safe manner in less than two minutes. The technology behind the linear accelerator is intensity modulated radiation therapy (IMRT), wherein healthy tissue is spared as the beams of radiation are precisely metered to deliver only the intensity required to treat

Pikeville Medical Center

the cancer. As the RapidArc rotates around the patient, speeding the delivery of radiation, the beam continues to modulate in intensity to avoid healthy structures. The Eclipse Treatment Planning System is used to preprogram the radiation based on the patient’s tumor and body habitus. To achieve an even higher degree of precision, PMC employs image-guided radiation therapy (IGRT), wherein the patient’s tumor is scanned before treatment, giving a last minute measurement of the tumor’s precise location. In addition, a Toshiba Aquilion Oncology CT scanner is used to evaluate tumor motion during the respiratory cycle adding delivery of high dose radiation specifically to the tumor. These therapies are most commonly used for prostate, lung, breast, colon, esophagus and pancreas cancers.

Award Winning Care, Continued Growth

Gynecologic Oncology Expertise

To address the high incidence and mortality of gynecologic cancers in Kentucky, LLCC recently recruited the region’s first gynecologic oncologist, Holly Gallion, MD. Treating malignancies of the ovary, uterus, cervix, vulva and vagina for over 20 years, Gallion manages patients from diagnosis to treatment to follow up. “It’s a unique specialty,” she says, “because it is focused around a limited number of tumors but involves multimodal therapies.” Those therapies include chemotherapy, surgery and some radiation management. Gallion is often called upon to evaluate or remove a suspicious pelvic mass that before would have required a patient to travel outside the area for treatment. When cancer is found, Gallion can coordinate all of the care locally,

Oncology Group (GOG) trials. “What’s really special about the Leonard Lawson Cancer Center at Pikeville Medical Center is that we are very committed to providing high quality health care. I will provide the best care I can regardless of a person’s ability to pay,” says Gallion. “Here, patients are treated like family members.”

Dr. John Simmons, radiation oncologist, has been instrumental in bringing the best available radiation technology to the region.

and her special training in complicated pelvic surgeries – such as the removal of fibroids and adhesions or the repair of bladder and bowel injuries – helps to reduce the incidence of invasive cancers later on. In the past five months, Gallion has opened several research trials at LLCC. One patient, she recalls, was able to receive her drug therapy without charge because of a newly opened NCI-sponsored trial. Others are benefitting from Gynecologic

Pikeville Medical Center has received the Commission on Cancer’s Outstanding Achievement Award. The Inpatient Oncology Unit has won the Excellence through Insight Award from HealthStream Research. This type of national recognition exemplifies PMC’s efforts to put patients’ needs first – often ahead of profit. Outreach clinics in surrounding communities reduce the travel burden for those for whom a drive to Pikeville may still be inconvenient. Providers meet weekly to discuss cases during tumor boards and to plan the next steps in LLCC’s development growth objectives. Currently, PMC is preparing a brand new facility to accommodate the cancer center’s rapid growth. LLCC’s new home will allow the cancer center to continue to align with Pikeville Medical Center’s mission to provide quality regional health care in a Christian environment. ◆ October 2011 23

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24 M.D. Update

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Markey Announces High Survival Rates for Many Cancers

LEXINGTON New data released officially on September 6, 2011 shows University of Kentucky Markey Cancer Center patients who have certain types of cancer have higher survival rates than patients with the same cancers treated elsewhere in the state or even the nation. Markey patients have significantly better five-year survival rates than those Kentucky cancer patients who were treated elsewhere for brain, breast, liver, lung, ovarian, pancreatic and prostate cancer, as well as for stage IV colorectal cancer. For example, Markey patients treated for liver cancer are two-and-a-half times more likely to survive five years after their cancer diagnosis when compared to other Kentucky patients. Other significant numbers include higher rates of survival after five years for lung (18 percent), ovarian (23 percent), brain (36 percent), and Stage IV colorectal cancer (49 percent). In addition, Markey patients with brain, lung, liver and ovarian cancers show higher five-year survival rates than patients treated at other cancer centers nationwide. Data on Markey’s cancer survival rates was gathered by Markey researchers, and the results were compared to those from the Kentucky Cancer Registry and the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program. Data was collected from 19982007 and the selection criteria included patients older than 20 years of age who were experiencing their first primary malignant cancer only. All patients were actively followed throughout the treatment process and for the subsequent five years after treatment. Dr. Mark Evers, director of the Markey Cancer Center, describes the new data as a measure of Markey’s quality of care, and he predicts that soon all cancer centers will be required to release similar data for the public. As a major referral center for the Commonwealth, Markey often takes in the most difficult cancer cases from physicians

around the state. This makes the data regarding survival rates even more impressive, says Dr. Thomas Tucker, the associate director for cancer prevention and control at Markey. “University cancer centers often see more difficult and advanced cancer cases. In general, the survival is not as good for these patients,” Tucker said. “Therefore, it is especially noteworthy that Markey Cancer Center Patients had better survival rates in nearly every category.” The University of Kentucky’s status as an academic medical center means patients have access to a wide variety of specialists — including residents and attending physicians — who can collaborate on their care, said Evers. “Here at Markey, patients have the benefit of true multidisciplinary care,” Evers said. “Health care providers from different medical areas and specialties work together to determine the best course of treatment for our patients. It’s that team approach that makes the biggest difference in our survival rates.” For example, Markey’s survival outcomes for liver cancer are substantially higher because of the center’s access to the UK Transplant Center. For many liver cancer patients, the most successful treatment will require a liver transplant, and UK’s transplant surgeons can work with Markey’s physicians to provide the surgery and follow-up care. Markey is also home to major cancer research, with hundreds of clinical trials underway at any given time. In addition to receiving new and experimental treatments in these trials, Markey patients have the advantage of visiting their physician on a regular basis. Screenings have made a difference, as well, helping physicians catch cancer in its earliest and most curable stages. The Ovarian

Cancer Screening Program, run by Dr. John van Nagell, provides free cancer screenings by transvaginal ultrasound (TVS) to postmenopausal women over the age of 50 or over the age of 25 with a family history of the disease. Additionally, UK is home to some of the most advanced cancer-treating technology available. The GammaKnife Perfexion, the TomoTherapy Hi-Art system, and stereotactic body radiation therapy are noninvasive ways to reach tough-to-reach tumors of the body — these systems use radiation beams to precisely target tumors with minimal effect on surrounding tissue. While the data highlights the efforts Markey has made to elevate patient care, Evers notes that there’s always room to grow and improve. In September 2012, the center plans to further boost its quality of care by applying for cancer center designation by the National Cancer Institute. Only 66 other centers in the country have earned this prestigious designation, and Kentucky is one of 16 states that currently do not have an NCI-designated cancer center. Benefits to earning an NCI designation include up to $1.5 million annually in funding, access to nationwide clinical trials, and an increase in community engagement including volunteers, patient advisory groups, and education and intervention programs. “Kentucky’s cancer rates are among the highest in the nation — the state needs an NCI-designated cancer center to provide for Kentuckians,” Evers said. “But the NCI doesn’t award these designations lightly. We’ve made this designation a major goal at Markey, and our work so far reflects that. We’re doing everything we can to prepare for our application next fall.” ◆ October 2011 25

news

in hematology and oncology at Maimonides Medical Center, also in Brooklyn. Prior to joining Commonwealth, Peru served as an assistant professor at the University of Iowa Hospitals & Clinics (Iowa City), as well as a full-time consultant with the Geisinger-Fox Chase Cancer Center in Wilkes-Barre, PA. Peru is an active member of the American Society of Clinical Oncology.

Breast MRI Accreditation for Jewish Hospital Medical Center East

Dr. Sirisha Peru

Perumandla Joins Commonwealth Cancer Center

Commonwealth Cancer Center announces the arrival of physician Sirisha Perumandla (Peru), MD to its network of Kentucky cancer centers. She will be seeing patients in Commonwealth’s Danville and Russell Springs locations. Peru is board certified in medical oncology, hematology and internal medicine. She practices general medical oncology, including solid tumors, myeloma, lymphoma, and some forms of leukemia, as well as general hematology, including disorders of bleeding and thrombosis. Peru received her medical degree from Osmania Medical College in South India. She completed her internal medicine residency at Coney Island Hospital in Brooklyn, New York and then went on to complete a fellowship

DANVILLE

Louisville Jewish Hospital Medical Center East (JHMCE) has been awarded a threeyear term of accreditation in breast magnetic resonance imaging (MRI) as the result of a recent review by the American College of Radiology (ACR). It is the only facility in Louisville to receive this accreditation. MRI of the breast offers valuable information about many breast conditions that may not be obtained by other imaging modalities, such as mammography or ultrasound. “We’re honored to be the first facility in the city to receive this prestigious recognition,” said Shelley Neal, president, Jewish Hospital Medical Center East. “Accreditation from the ACR distinguishes our organization as the foremost provider of care for women in the region.” “This accreditation confirms that our experienced MRI technologists are producing high quality exams which allow my partners and I to better detect subtle abnormalities in the breast,” said Frank Lee, M.D., Radiology Specialists of Louisville. “This is

just another example of the very high quality service we continue to provide, not only in Women’s Imaging but throughout our medical imaging department.” The ACR accreditation represents the highest level of image quality and patient safety. It is awarded only to facilities meeting ACR Practice Guidelines and Technical Standards after a peer-review evaluation by board-certified physicians and medical physicists who are experts in the field. Image quality, personnel qualifications, adequacy of facility equipment, quality control procedures, and quality assurance programs are assessed. The findings are reported to the ACR Committee on Accreditation, which subsequently provides the practice with a comprehensive report they can use for continuous practice improvement.

Joint Commission Names Top Performers on Key Quality Measures

LEXINGTON Among the 405 US hospitals recognized as “Top Performers on Key Quality Measures” by The Joint Commission, Central Baptist Hospital of Lexington is the only Kentucky-based JC accredited hospital receiving recognition in the four key categories of adult care: heart attack, heart failure, pneumonia, and surgical care. Other Kentucky hospitals receiving “Top Performer” recognition include: Saint Joseph Health System – Berea (surgical); Greenview Regional Hospital, Bowling Green (pneumonia, surgical); Frankfort Regional Medical Center,

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Surgical Associates of Louisville joins Baptist Surgical Associates LOUISVILLE Surgical Associates of Louisville has joined Baptist Surgical Associates. Physicians in the group are: Janet R. Chipman, MD, a 1990 graduate of the University of Louisville School of Medicine. She completed her general surgery internship and residency at University of Louisville Hospital in 1995. She is board-certified in general surgery. Marc A. Marcum,

MD, a 1986 graduate of the University of Louisville School of Medicine. He completed his general surgery internship and residency at University of Louisville Hospital in 1991. He is board-certified in general surgery. Richard M. Pokorny, MD, a 1992 graduate of the University of Louisville School of Medicine. He completed his general surgery internship and

residency at University of Louisville Hospital in 1998. He completed a fellowship in general surgery at Shawnee Mission Hospital in Kansas City, Kan., in 1998. He is board-certified in general surgery. Gregory L. Stevens, MD, a 1979 graduate of the University of Louisville School of Medicine. He completed his general surgery internship and residency at University of Louisville Hospital in 1984. He is board-certified in general surgery.

performance data reported to The Joint Commission during the previous calendar year. Top performers earn 95% or above on performance targets. “Today, the public expects transparency in the reporting of performance at the hospitals where they receive care, and The Joint Commission is shining a light on the top performing hospitals,” says Mark R. Chassin, MD, FACP, MPP, MPH, president of The Joint Commission.

Dunbar joins Baptist Medical Associates

LOUISVILLE Elmer Dunbar, MD, pain management, has joined Baptist Medical Associates. His practice, the Baptist Center Pikeville Medical Center

Dr. Janet Chipman

Dr. Marc Marcum

Frankfort (heart failure, pneumonia, surgical); Hospital of Fulton, Inc., Fulton (pneumonia, surgical); Harlan Appalachian Regional Hospital, Harlan (heart failure, pneumonia, surgical); Jackson Hospital Corp., Jackson (pneumonia); Spring View Hospital, Lebanon (pneumonia, surgical);

Dr. Richard Pokorny

Dr. Gregory Stevens

Hospital of Louisa, Inc, Louisa (pneumonia, surgical); and Logan Memorial Hospital, Russellville (pneumonia). No Kentucky hospital was named “Top Performer” in Children’s Asthma, the fifth award category. These achievements are based on

Dr. Elmer Dunbar

October 2011 27

news for Pain Control, is located at Baptist Eastpoint, 2400 Eastpoint Parkway. Dunbar is a 1978 graduate of the University of Louisville School of Medicine. He completed his anesthesia internship at University of Louisville Hospital in 1980 and residency at the University of Cincinnati in 1981. He is board-certified in interventional pain and anesthesia with certification in pain management, and is a fellow of interventional pain practice of the World Institute of Pain.

$1.5 Million Gift to Cardiovascular Innovation Institute

LOUISVILLE The Roger M. Prizant Charitable Lead Annuity Trust is providing a gift of $1.5 million to support the research at the Cardiovascular Innovation Institution into the causes and management of endstage heart disease. The gift is to the Jewish Hospital & St. Mary’s Foundation. CII is a joint venture between Jewish Hospital & St. Mary’s HealthCare and the University of Louisville.

To honor Prizant, the administrative offices of CII will be named the Roger M. Prizant Administrative Offices. CII dedicated the offices in a ceremony for members of the Prizant family, representatives of the Foundation and supporters of CII on October 9. Prizant was a graduate of the University of Louisville Law School, and until his death in 2009 at age 66, was a member of The Temple, the Louisville Bar Association and the Kentucky Bar Association. He practiced real estate law for many years. In 1985, he formed Mesa Foods which manufactured Chi Chi’s tortilla and corn chips as well as many other products, and had several hundred employees. After retiring from Mesa Foods, he became an owner of several Fire Fresh Restaurants. Prizant was the recipient of a ventricular assist device and transplant at Jewish Hospital in the 1990s. He made the donation to the CII to support research in heart failure.

Moliterno Named New Chair of Internal Medicine

LEXINGTON David J. Moliterno, MD is the new chair of the Department of Internal Medicine at University of Kentucky College of Medicine, effective Aug. 1, 2011. An interventional cardiologist, Moliterno has served in several capacities since his arrival to UK in 2004, such as the Jefferson M. Gill Professor of Cardiology, chief of the Division of Cardiovascular Medicine, vice-chair of the Department of Internal Medicine, and medical director of the Gill Heart Institute. Moliterno succeeds Dr. Frederick C. de Beer, who was recently appointed dean of the College of Medicine and vice president for clinical academic affairs. Moliterno received his medical degree from the Medical College of Virginia, and his internal medicine training from Vanderbilt University Hospitals. He completed a fellowship in cardiovascular medicine at the University of Texas-Southwestern Medical Center, and he completed an additional

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news interventional cardiology and research fellowship at the Cleveland Clinic Foundation, where he remained as an attending staff cardiologist for 10 years before joining the University of Kentucky in 2004. Moliterno is a fellow of the American College of Physicians, European Society

Dr. David Moliterno

of Cardiology, Society for Cardiovascular Angiography and Interventions, American Heart Association, and the American College of Cardiology. He is the immediate past Governor for the American College of Cardiology-Kentucky Chapter. He also is a member of the Association of Professors of Cardiology and Association of University Cardiologists. He has been voted among the Best Doctors in America since 2001 and is a life member of the National Registry of Who’s Who. Moliterno has been a visiting professor or invited lecturer in more than 30 countries. Moliterno is the author or coauthor of over 250 publications, including 55 book chapters, and five textbooks. He has been the primary author of publications in Circulation, JACC, JAMA, Lancet, and the New England Journal of Medicine.

Matheny Named Assistant Provost for Global Health Initiatives

LEXINGTON Dr. Sam Matheny, professor and former chair of the UK College of Medicine Department of Family and Community Medicine, and UK College of Medicine alumnus, has accepted the position of Assistant Provost for Global Health Initiatives at the University of Kentucky. In Matheny’s new role he will work to coordinate potential affiliations with international partners for all of UK’s health sciences colleges, and oversee global health programs October 2011 29

news plinary setting because that is going to be very important to the future of medicine.”

Gill Heart Cardiac Rehab, Frazier Pulmonary Rehab, and Jewish Cardiac Rehab Certified for Quality of Life Enhancing Care

Dr. Sam Matheny

in the College of Medicine, including the new Global Health Track. He will also focus on interprofessional learning, particularly service learning, and work with the health sciences colleges to develop programs in research, education and engagement. “Participating in global health initiatives is such a great experience for our students, and it benefits our communities as well,” Matheny said. “There is evolving data that students interested in global health are more likely to work in underserved areas in the United States. As an academic medical center, we want to prepare our students to work in underserved areas in a multidisci-

LEXINGTON | LOUISVILLE Three Kentucky heart & lung rehabilitation programs report certification by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) in recognition of their commitment to improving the quality of life by enhancing standards of care. Frazier Rehab Institute received certification in pulmonary rehab, and Jewish Hospital’s Garon Lifestyle Center and UK HealthCare Gill Heart Institute Cardiac Rehabilitation Program received certification in cardiac rehab. AACVPR certification is meant to provide a benchmark for best practices, program quality and improving patient outcomes. The Association provides a systematic approach to quality care and promotes a culture of quality patient care. AACVPR is the only

organization that certifies cardiac and pulmonary rehab programs. AACVPR Program Certification is valid for three years. The AACVPR Program Certification is the only peer-reviewed accreditation process designed to review individual programs for adherence to standards and guidelines developed and published by the AACVPR and other professional societies. The one-month application process requires extensive documentation of each program’s practices. Each program is reviewed by the AACVPR National Certification Committee and certification is awarded by the AACVPR Board of Directors.

Grand Opening for Shawnee Christian Healthcare Center

The Shawnee Christian Health Center, the only medical facility in the Shawnee neighborhood which comprises more than 17,000 residents, celebrated its grand opening Friday, September 9. Shawnee Located at 234 Amy Ave., Shawnee Christian Healthcare Center is dedicated to caring for the underserved and focused on providing

LOUISVILLE

Continues on page 32

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Grand Opening of Cardinal Hill Rehabilitation Hospital Patient Care Building

Cardinal Hill Hospital Board members at the Ribbon Cutting of the Patient Care Building on September 13, 2011: (l-r) Dr. Russell Travis, Associate Medical Director; Glenn Norvell, Chair of the Board of Trustees; J. Hagan Codell; Roger Dalton; Gregg Thornton, Building Committee Chair; Jimmy Nash, Immediate Past Chair of the Board of Trustees; and Charlotte Lundergan; Paul Honeycutt, Mike Kanarek, Chair Kess; Warren Hoffman; Ken Hiler (kneeling)

Lexington Medical Society Golf Outing

LMS president-elect Dr. Bruce Broudy and LMS Golf Chair Dr. John Collins enjoy the end of a successful day of golf at the University Club of Kentucky at the LMS Annual Golf Outing on Sept. 21, 2011.

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KMA Annual Meeting

Delegate members of the Lexington Medical Society pause for a group photo at the annual KMA Meeting in Louisville on September Sept. 12-14, 2011: (l-r) Dr. Hollis Hilty; Dr. W. Lisle Dalton; Dr. Farhad Karim, LMS President;Dr. Nat Sandler; Dr. Thomas Slabaugh Sr., KMA Past President; and Carolyn Kurz, LMS Executive Director.

More Lexington Medical Society delegate members pose with out-going KMA president Gordon Tobin: (l-r) Dr. Barbara A. Phillips; Dr. Preston Nunnelly; Dr. Gordon Tobin; Dr. Robert Granacher; Dr. Rice Leach; and Dr. Bruce Broudy.

Greater Louisville Medical Society Foundation Scholarship Golf Tournament

Playing in the GLMS Foundation Scholarship Gold Tournament on Sept. 19, 2011: (l-r) Dr. David Watkins, GLMS Golf Chair; Ron Daniel; Danny Watkins; Ryan Tuss; and Woody Long.

It was all smiles for GLMS Scholarship supporters Steve Schulz; Bonnie Ciresi; Dr. Linda Gleis, GLMS Scholarship Chair; Eric Gleis; and Jimmy Ford.

October 2011 31

news Continued from page 30

care for the whole person - physically, spiritually, socially and psychologically, emphasizing preventive health care and wellness. “The Shawnee Christian Healthcare Center Board of Directors is excited and grateful to be a part of this project,” said David Dageforde, MD, cardiologist and board president. “Our goal is to not only bring primary health care that focuses on caring for the whole person and emphasizes wellness to the Shawnee neighborhood, but also to implement neighborhood programs that result in permanent change.” The center cares for children and adults regardless of their ability to pay. In addition to providing care for the Shawnee neighborhood, the health care center promotes neighborhood transformation programs that include access to healthy food options, educational nutritional classes, walking clubs that encourage physical activity and other community development initiatives. Norton Healthcare provided $425,000 in financial support, in addition to many inkind donations, to help set up and furnish

the center. “Norton Healthcare is pleased to be a partner and donor to the Shawnee Christian Healthcare Center,” said Steven T. Hester, MD, MBA, system senior vice president and chief medical officer. “Our organization has implemented many screening and wellness initiatives in West Louisville to help improve the overall health status of residents in this area. By providing financial and in-kind donations to help further the mission of the center, we can continue to help meet the needs of West Louisville and the Shawnee neighborhood, in particular.”

VanMeter Named One of America’s Top Ophthalmologists

LEXINGTON Woodford VanMeter, professor in the Department of Ophthalmology and Visual Sciences at the University of Kentucky College of Medicine, has been named one of America’s leading ophthalmologists by Becker’s ASC Review, the leading source for business and legal news for ambulatory surgical centers.

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The list, ‘135 Leading Ophthalmologists in America,’ recognizes outstanding ophthalmologists in health care organizations across the country. The ophthalmologists named to this list lead their field in clinical and research efforts, furthering the practice of ophthalmology with their hard work, knowledge and dedication to the specialty. The chosen ophthalmologists were selected for the list based on the awards they receive from major ophthalmic organizations, their leadership in these organizations, work on professional publications and positions of service. ◆

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