THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS AND HEALTHCARE PROFESSIONALS ISSUE #89
SPECIAL SECTION
Oncology
GAME CHANGER
Dr. Jason Chesney and the U of L Brown Cancer Center, a part of KentuckyOne Health, are the first in the region to offer a new class of drugs that is prolonging life in stage 4 melanoma patients ALSO IN THIS ISSUE
VOLUME 5, NUMBER 6
PREVENTING BREAST CANCER IMPROVING ACCESS TO
BREAST CANCER CARE FRAMELESS RADIOSURGERY PAIN RELIEF FOR METASTATIC SPINAL TUMORS RELATIONSHIP-BASED CANCER CARE
University of Louisville Hospital’s James Graham Brown Cancer Center is the BEST in Louisville for Cancer Care.
This year, one Louisville cancer center – and only one – was recognized by U.S. News and World Report for treatment of cancer at a national standard of excellence: University of Louisville Hospital’s James Graham Brown Cancer Center. Many of the complex procedures we perform are available to cancer patients in our region only at James Graham Brown Cancer Center. Our robust clinical and basic science research program provides the best opportunity for discovery of new techniques and therapies for cancer treatment. At the forefront of pioneering science and clinical excellence, University of Louisville Hospital’s James Graham Brown Cancer Center, part of KentuckyOne Health, is the one name for cancer treatment. KentuckyOne Health. The one name in cancer care.
LETTER FROM THE PUBLISHER
The Mentoring Tree There’s a recurring theme in MD-UPDATE that I call “the Mentoring Tree.” Nearly every physician we talk with has a “mentor” story to tell. Some of the mentors are their physician father or a family doctor growing up. Most frequently, the mentor shows up in medical school or during residency rotation. Dr. David Bensema, president of the Kentucky Medical Association and pastpresident of the Lexington Medical Society, spoke passionately about mentoring in his address to the membership at the society’s past-presidents’ dinner. “Find a young physician to mentor,” Bensema said. “It will benefit you as well as them. It will re-kindle your interest and excitement for why you got into medicine in the first place.” In the cover story of MD-UPDATE Issue #88, Linda Gleis, MD, who is past-president of the Greater Louisville Medical Society and has taken on many other roles in Kentucky medicine, recalled the influence of her mentors, such as Dr. Ken Peters on her decision to be involved in organized medicine. Dr. Linda Gleis herself is seen as a profoundly influential mentor of many physical medicine and rehabilitation specialists who came through U of L, as evidenced by Dr. Darryl Kaelin, current medical director of Frazier Rehab Institute and chief of the division of Physical Medicine & Rehab at U of L. Kaelin, we suggest, will one day be seen in a similar role, and so on it goes. It’s common in sports now to talk and speculate on the “coaching tree” of established basketball and football coaches whose players, assistant coaches, and sons are now coaches. I laughed when I read that Richard Pitino, son of Rick and current coach of University of Minnesota’s basketball team, said that his famous father would probably try “to coach both teams at once” when the University of Louisville plays Minnesota on November 14. That’s a case of “mentoring” that won’t give up. The point is mentoring is a deeply ingrained fact of a physician life. As Bensema said, “It’s our professional obligation. We are lifelong learners and educators. It’s our role to teach the next generation of doctors.” So, who was your mentor? Who are you mentoring? Please contact me if you have a “mentoring story” you want to tell. All the Best, Gil Dunn Publisher, MD-UPDATE
Send your letters to the editor to: jnewton@md-update.com, jnewton@md-update.com, or (502) 541-2666 mobile Gil Dunn, Publisher: gdunn@md-update.com or (859) 309-0720 phone and fax 2 MD-UPDATE
Volume 5, Number 7 ISSUE #89 PUBLISHERS
Gil Dunn PRINT gdunn@md-update.com Megan Campbell Smith DIGITAL mcsmith@md-update.com EDITOR IN CHIEF
Jennifer S. Newton jnewton@md-update.com GRAPHIC DESIGNER
James Shambhu art@md-update.com
CONTRIBUTORS: Jan Anderson, PsyD, LPCC Anthony Dragun, MD Scott Neal Dave Peterson Porter Roberts Matthew Smith Stephanie Smith Susan Smith Stephanie Wurdock
CONTACT US:
ADVERTISING AND INTEGRATED PHYSICIAN MARKETING:
Gil Dunn gdunn@md-update.com
Mentelle Media, LLC
38 Mentelle Park Lexington KY 40502 (859) 309-0720 phone and fax Standard class mail paid in Lebanon Junction, Ky. Postmaster: Please send notices on Form 3579 to 38 Mentelle Park Lexington KY 40502 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 2013 Mentelle Media, LLC. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means-electronic, photocopying, recording or otherwise-without the prior written permission of the publisher. Please contact Mentelle Media for rates to: purchase hardcopies of our articles to distribute to your colleagues or customers: to purchase digital reprints of our articles to host on your company or team websites and/or newsletter. Thank you. Individual copies of M.D. Update are available for $9.95.
CONTENTS
ISSUE #89
COVER STORY 4 HEADLINES
6 LEGAL
8 FINANCIAL
9 ACCOUNTING
10 Q&A
12 COVER STORY
15 SPECIAL SECTION
GAME CHANGER
Dr. Jason Chesney and the U of L Brown Cancer Center, a part of KentuckyOne Health, are the first in the region to offer a new class of drugs that is prolonging life in stage 4 melanoma patients
Dr. Jason Chesney talks with IV Pharmacy Tech Julie Ray in the Brown Cancer Center research pharmacy, where test agents are prepared, prior to infusion into advanced cancer patients.
ONCOLOGY
24 COMPLEMENTARY CARE
27 NEWS
30 EVENTS
BY JENNIFER S. NEWTON PHOTOGRAPHY BY BRIAN BOHANNON PAGE 12
SPECIAL SECTION ONCOLOGY
15 IMPROVING ACCESS TO BREAST CANCER CARE: U OF L
17 TARGETING TUMORS AND MORE: NORTON CANCER INSTITUTE – DOWNTOWN
18 PRACTICING PREVENTION: CANCER CENTER OF INDIANA
20 RELATIONSHIP DRIVEN: GEORGETOWN COMMUNITY HOSPITAL
22 PAIN RELIEF FOR METASTATIC SPINAL TUMORS: CARDINAL HILL PAIN INSTITUTE
ISSUE#89 3
HEADLINES
Ironcology
Physician triathlete runs, swims, and bikes to raise funds for cancer patients at UK BY GILL DUNN
cers, plus some pediatric oncology patients. Ironcology is the name Feddock gave to his effort to raise funds for a new brachytherapy suite at MCC. His goal was to raise a $200,000 down payment on the $1.2M renovation that will bring brachytherapy treatment and recovery under one roof at Markey, along with the purchase of new equipment, such as a new CT scanner and new radiation planning and delivery equipment. “A new, consolidated brachytherapy suite will provide a safer, faster, and better patient experience,” says Feddock. The idea to turn his passion for competitive triathlons into a fundraiser came to Feddock from a news story in New York where a local TV anchorman started in last place in the New York City Marathon and received pledges for each runner he passed.
The easiest part of Dr. Jonathan Feddock’s daily regimen is training for a full scale Ironman triathlon, he says. That’s an open water 2.4-mile swim, a 112-mile bike race, followed by running a marathon distance of 26.2 miles. That’s a total of 140 miles, all in one day, competing against highly conditioned fellow amateurs and elite professional athletes. The most challenging part, Feddock says, is maintaining the blog, Twitter, Instagram accounts, and website, (www.ironcology.org) that have propelled his idea of “Ironcology” into a crowdsourcing phenomenon for the Markey Cancer Foundation (MCF) at UK Healthcare. Being a radiation oncologist at UK’s Markey Cancer Center (MCC), father of two boys, and husband to wife, Shannon Florea, MD, who is a rheumatologist, are “inbetween there somewhere,” he says. Feddock came to UK on a track scholarship as Dr. Jonathan Feddock, (ABOVE) an undergraduate studying radiation oncologist with UK Markey Cancer Center, puts his pre-med. After two years, passion for triathalons to work he gave up competitive colas a fundraiser for cancer, legiate running to focus on which he calls “Ironcology.” academics and getting into medical school. He was Markey Cancer Foundation accepted at the UK College CEO Stephanie Herron of Medicine, met his wife immediately saw the media there, and matched for resiand donor rallying potential of dency as well. On staff at Feddock’s idea and suggested the crowd-sourcing format. UK since 2012, Feddock concentrates his oncology practice on breast, ovarian, uterine, and cervical canLEXINGTON
4 MD-UPDATE
PHOTOGRAPHS BY GIL DUNN
Feddock recalls thinking, “I can do that, but probably pass a lot more runners.” He took his idea to Stephanie Herron, CEO of MCF, who saw the potential of the fundraiser and suggested the crowdsourcing format, the first of its kind for UK Healthcare and the University of Kentucky. “We were looking for an idea that social media could get hold of, something that donors of all levels could rally behind. With Dr. Feddock’s passion for his patients, his work, and triathlons, it all came together very easily,” says Herron. Feddock started with just a blog and a very simple website. He created the Ironcology logo “in about 30 minutes on my PC,” he says. Next, came Twitter and Instagram accounts. “My blog was mostly about my patients,” says Feddock, “with a little about my training.” Slowly the blog and website attracted more visitors and hits, averaging about 200 per day. When UK head basketball coach John Calipari put a post about Feddock and Ironcology on the coach’s Facebook page, Ironcology received 1800 hits in three hours. “That was huge,” says Feddock. Then a momentous event happened. IRONMAN, the international organizer of Ironman triathlons, learned about Feddock and Ironcology and anointed him the “featured runner” of the Ironman event in Louisville in August 2014. Feddock was chosen to give the pre-race pep-talk to all 2100 competitors the night before, where he described Ironcology and his motivation for competing. The next day, race day, a camera crew on boat, on land, and on bike followed Feddock throughout the entire race.
It helped him stay focused, he says. “There were times when I felt like walking, but then I saw the camera man and kept running.” Feddock’s venture raised $17.61 for each fellow racer that he passed. “There were almost 2100 competitors; I passed 1977 of them,” he says. “I wanted to be in the top 50, but I kind of faded at the end.” Additional funds have come from donations to the MCF from individuals who read his blog, follow him on twitter, or visit the Ironcology website and are moved by what he is doing. “I’ve been contacted by people across the country and even by people coming up to me in Kroger,” says Feddock. “One woman said, ‘You don’t know me, but I know you. You’re treating the little girl on my street for cancer. Let me
give you a check.’ I accepted it but made sure she made the check out to the Markey Cancer Foundation.” “The biggest surprise has been the number of people who have reached out and supported me,” says Feddock. Crowdsourcing success comes from awareness. “My fellow physicians have supported me in many ways, through donations and awareness.” Feddock also credits the MCF for helping him manage the donations, receipts, website, and all the details. “Being the first crowdsourcing venture here, we were learning along the way,” he says. To date, Ironcology has raised over $120,000 in donations, large and small.
The board of MCF has pledged $75,000 from proceeds of a recent fundraising event in which some of Feddock’s supporters contributed high end auction items. Feddock is confident that the $200,000 will be achieved before his next goal, which is qualifying for the big Ironman in Kona, Hawaii, and competing for the world championship. He also plans to start a local Ironcology group of cancer survivors who use triathlons and athletics to help them recover from cancer. ◆
Supporting Kentucky’s only NCI designated Cancer Center. MARKEY AFFILIATE LOCATIONS UKMarkey.org
Conquering Cancer in Kentucky
PHOTOGRAPHS PROVIDED BY MARKEY CANCER FOUNDATION
ISSUE#89 5
LEGAL
When Hospice Works Too Well The first US hospice program opened its doors in 1974. Today, there are more than 5,500 hospice agencies serving an estimated 1.65 million Americans. As the Baby Boomer generation ages, an increasing number of terminally ill individuals are taking advantage of the compassionate care and dignified existence available to them through the Medicare hospice benefit. These patients have generally been shown to enjoy a higher quality of life during their last few months of life and, in some cases, have outlived their six-month life expectancy. But what happens when hospice works too well and its patients routinely exceed the estimated six-month life expectancy? While lengthened life expectancies are often a cause of great joy for hospice patients and their families, they can also have severe legal and financial ramifications for the hospice provider. This article will briefly discuss those ramifications and how to avoid them. To be eligible for hospice, a patient must be certified by his or her attending physician and the hospice physician as being terminally ill with a prognosis of six or fewer months to live. The potential patient must agree to refuse all curative care while enrolled in the hospice program. If the patient recovers from the illness, he or she must be discharged. A hospice patient may remain in hospice for more than six months only if the physician re-certifies that the patient’s life expectancy remains fewer than six months. When hospice care began roughly 40 years ago, care was focused on cancer patients whose life expectancy was relatively easy to predict. Now, hospice accepts patients with a vast array of terminal illnesses, the duration of which can be difficult to stage, such as non-Alzheimer’s dementia, Parkinson’s, and Failure to Thrive. Indeed, some prognoses are so speculative that a patient may actually be discharged from hospice altogether. In the year 2011, 278,000 patients were discharged alive from hospice for many reasons, including extended prognosis. According to a new study by Medicare, 6 MD-UPDATE
the number of “live” discharges now represents more than one third of hospice patients. In recent years, the Health and Human Services Office BY Stephanie M. Wurdock of the Inspector General (OIG) has grown suspicious of the number of “live” discharges and hospice stays longer than six months. The OIG is addressing these suspicions by implementing annual “Work Plans.” The OIG’s 2012 “Work Plan” included ongoing review and assessment of the “appropriateness” of hospice care claims. The 2013 Work Plan scrutinized the relationships between nursing homes and hospice agencies, stating that “82 percent of hospice claims . . . in nursing facilities did not meet Medicare coverage requirements.” The 2014 plan dictates that the OIG will “review the extent to which hospices serve Medicare beneficiaries who reside in assisted living facilities (ALFs).” The 2014 Work Plan also states the OIG’s intent to review general inpatient hospice medical records for potential misuse. So why is the OIG so concerned with hospice admissions? After all, shouldn’t we be thrilled the terminally ill are living longer? The answer is in the numbers, specifically the dollars. Hospice care is a billion dollar industry. Medicare pays for approximately 84 percent of all hospice patients, and Medicare expenditures for hospice benefits have increased approximately $1 billion per year since 1998. In an effort to control these monumental expenditures, the OIG is auditing hospice agencies across the country. In the last several years, two prime areas of investigation have surfaced: (1) relationships between hospice programs and skilled nursing facilities; and (2) hospice marketing materials. In order to avoid
incurring sanctions and penalties by the OIG, hospice agencies should take care to comply with regulations regarding these two areas of concern. First, hospice agencies must monitor the number and percentage of patients they serve in nursing homes and pay special attention to ensure their patients meet all admission criteria. Hospice agencies must also be diligent about documenting certification of a patient’s terminal status for every new admission. This includes documenting that the certifying physician physically examined the patient prior to certification. Once the patient is admitted, his or her chart must be routinely audited. If a Medicare covered patient is still alive six months after being admitted to hospice care, the physician must recertify the patient’s terminal status. If not re-certified, the patient must be promptly discharged. Hospice agencies must also avoid entering into any referral arrangements with nursing homes, assisted living facilities, or physicians that run afoul of the federal anti-kickback laws. Likewise, hospice admissions staff should not receive bonuses related to number or type of admissions, or length of stay. All referral arrangements should be reviewed by legal counsel before implementation. Next, a hospice agency’s marketing materials must clearly and accurately state the requirements for hospice certification, i.e., the patient must have a six-month terminal status and agree not to receive any curative treatment. These terms and conditions must be explained to the patient and his or her family before and at the time of hospice admission. As with referral arrangements, all marketing materials should be approved by counsel. Hospice agencies that are found by the OIG to have improper policies, procedures, or documentation resulting in overpayments from the Centers for Medicare Services (CMS) can have their Medicare reimbursement, and potentially their program participation, suspended. Depending on the seriousness of the violation, these
hospice agencies are also at risk of incurring substantial monetary penalties. For example, in December 2011, an Arkansasbased hospice settled a False Claims Act suit for $2.7 million. In March 2012, a large hospice chain paid $25 million to settle a whistleblower action concerning false billing for services. To avoid these ramifications, hospice agencies should consult routinely with legal counsel to ensure that all admissions and exit policies, procedures, and practices are in compliance with state and federal regulations. Stephanie M. Wurdock is an attorney at Sturgill, Turner, Barker & Moloney, PLLC, where she defends long-term care providers against claims of negligence. She can be reached at (859) 255-8581 and swurdock@ sturgillturner.com. ◆
A Joint Commission accredited private surgery center where our physicians perform diagnostic and surgical procedures for the treatment of pain, to include:
Sturgill Turner’s health care legal team is committed to providing comprehensive legal services to health care professionals, institutions and managed care organizations.
Serving health care providers with integrity. LEXINGTON ◆ STURGILLTURNER.COM
THIS IS AN ADVERTISEMENT ISSUE#89 7
FINANCIAL
Retirement. What Retirement? Lately we hear many people asking, “Will I have to work for the rest of my life?” My response, “It depends.” I’m not trying to be flippant with my answer, because it truly is a serious question facing many people today. Some physicians already contemplate working until the end, so to them, the question is practically rhetorical. It remains a valid question, however. Let’s suppose for a minute that you are not one of the “die with your boots on” set. What then? Have recent events caused you to wonder if you will have to work longer, whether you want to or not? No matter where you are in your career, that question has a quantifiable answer, but it is not as simple as it may first appear. Also, if you are within 10 years of your targeted retirement there may also be some urgency to the issue. There are various ways to get at the answer to the question. Many planners, and most online tools, will address the question in three simple steps: 1) based on your expected income in the year just prior to retirement, first determine how much of your income needs to be replaced in retirement (some expenses will go away, they
will always spend less than income. However, the retirement goal that we hear most often is the desire to maintain living standard. It is not how much income that you have that deterBY Scott Neal mines your standard of living, but how much you spend to support your chosen lifestyle. It is spending, after taxes and payments on debt, that determines your living standard in any given year. The starting place for such a calculation is your current living standard matched against your satisfaction or dissatisfaction with it. Simply assuming that more income is the answer is not enough. Income is only one factor in determining living standard. Keep in mind that some people are actually satisfied with a level or even decreased living standard in retirement. Regardless of your direction, to base the whole analysis on income replacement
THE RETIREMENT GOAL WE HEAR MOST OFTEN IS THE DESIRE TO MAINTAIN LIVING STANDARD. say); 2) calculate the amount of investment assets that will be needed at the outset of retirement to produce that level of income; and 3) calculate the amount that you need to contribute to your investment portfolio each year between now and retirement date. While we like to make things simple, this process involves a bit of oversimplification. Let’s break down each of the calculations. Starting solely with income replacement as the goal is usually a misplaced priority in our opinion. We have all been taught that “living within one’s means” means that we 8 MD-UPDATE
is to miss a vital point. Assets, in addition to income, should enter into the equation. Secondly, depending solely on the investment portfolio to produce the income needed to replace your pre-retirement income can be misguided. What about social security and other forms of assistance? Assuming that you live only on income ignores the possibility of consuming your portfolio to some very old age, e.g. 100. If you die before then, the children will have an inheritance. Another factor: what will be your tax
bracket in retirement compared to preretirement? The stock advice of most planners has been to delay withdrawals from your retirement account until the required age of 70½ AND delay the start of social security benefits to age 70. Guess what? In some cases, that strategy could actually increase your tax bracket in retirement and could substantially increase the amount of taxes paid over the rest of your life. A better idea is to determine if smoothing the expected tax bracket will be beneficial. That might mean that you will pay more taxes in pre-retirement and less in retirement but because retirement is likely to be a much longer period of time, the total accumulated tax bill could be less. When dealing with the savings question, one has to ask whether it is possible to save too much. Savings always comes at the expense of current living standard. Remember too, that in addition to the terminal value needed in the portfolio at retirement there are multiple variables that must be considered when addressing such a goal. One must also assume a rate of return (which is not likely to be constant) on the assets that are accumulating. Furthermore, rarely do we see any programs that consider an increase in the amount of savings over time. That may be unrealistic since debts will be paid off eventually and children will hopefully be out of the house someday. In our opinion, the correct method of determining the answer to the question is vitally important. In addition to the goalsetting method above, we consider the problem from the perspective that gauges the effect that working more (or less) years will have on your family’s living standard, now and in the future. The economist’s term for this is “consumption smoothing.” Let us show you how it’s done. Scott Neal, a CPA and CFP, is president of D. Scott Neal, Inc. a FEE-ONLY financial planning and investment advisory firm with offices in Lexington and Louisville. He can be reached at scott@dsneal.com or toll free at 1-800344-9098. ◆
ACCOUNTING
10 Year-End Income Tax Planning Tips BY L. PORTER ROBERTS, JR., CPA, AND MATTHEW S. SMITH, CPA, CFE Even though the store aisles are already littered with holiday decorations, there is still time for you to minimize your 2014 income tax liability. As you likely experienced with your 2013 tax return, taxes have increased, and each year the rules become more complicated. Because of this, planning to keep your taxes to a minimum becomes that much more valuable. These 10 tax saving suggestions may help you keep more of what you earn.
Maximize Qualified Retirement Plan/401(k) Contributions
If you are not contributing the maximum amount to your retirement plan, we strongly encourage you to consider doing so. Not only does this go a long way towards meeting your retirement goals, but it could save you thousands in taxes. The 2014 401(k) deferral limit is $17,500. If you are age 50 or over by year’s end, you can contribute an additional $5,500 for a total of $23,000.
Utilize Pre-Tax Payroll Deductions
Some employers allow employees to participate in Section 125 or cafeteria plans. These plans allow employees to select from numerous benefits to be paid from their wages. Some plan benefits can be paid on a pre-tax basis including, health, dental, and vision insurance premiums, and dependent care benefits. Some employers also offer flex spending accounts or health reimbursement accounts. These plans allow physicians to pay for qualified medical expenses on a pretax basis, resulting in a potential savings of 40 percent or more.
Consider a Health Savings Account (HSA)
An HSA is a separate bank account used to pay for medical expenses. It must be coupled with a high-deductible health plan (HDHP). Contributions are made pre-tax
or are tax-deductible up to certain limits. Funds grow tax-free in the account, and disbursements are tax-free when used for qualifying medical expenses.
Consider Residential Energy Efficient Improvements
For 2014, certain costs related to qualified solar electric, solar water heating, small wind energy, and geothermal heat pump property costs are eligible for a tax credit of 30 percent of the costs associated with the property. We have had numerous clients install geothermal heat pumps that qualify for the tax credit. This is a great way to cut your tax bill in the year of installation and your utility bills for years to come.
Tax Planning for Non-Employees
Practicing as a sole proprietor allows you to take advantage of several additional tax breaks. Some common strategies and deductions include the self-employed health insurance deduction, the home office deduction, employing family members, medical reimbursement plans, paying rent to related parties, and retirement plans. Each of these options has specific rules and requirements that must be followed. When structured properly, each option could save you substantial tax dollars.
Capital Gains/Losses Planning
The tax rate on long-term capital gains can be 0 percent, 15 percent, 20 percent, 25 percent, or 28 percent depending on your taxable income and the underlying asset sold. In addition, the gain could be subject to the additional 3.8 percent tax on net investment income. Because of this, proper tax planning is essential. In certain situations, harvesting losses by selling a security that has decreased in value, then purchasing the same security at least 31 days later can be beneficial.
Make Up a Tax Shortfall With Increased Withholdings
If you are in a situation where you will be
subject to an underpayment penalty, consider making up the shortfall by increasing your tax withholdings between now and the end of 2014 instead of increasing your estimated tax payments. The withholdings are considered to be paid in evenly throughout the year, while estimated tax payments are factored into the calculation using the actual dates paid.
Utilize Your Annual Gift Tax Exclusion
For 2014, you can give up to $14,000 to as many people as you desire without gift or estate tax consequences. In addition, if you are married, you can combine gifts with your spouse to double the amount to $28,000 per person for 2014. You can utilize this exclusion each year to reduce your taxable estate. Also, it is possible to fund up to five years’ worth of annual gift tax exclusion amounts (currently $70,000) in one year into a 529 plan.
Think About Your Charitable Donations
Contributing appreciated stock (held one year or more) benefits you and the organization more than if you sell the stock and donate the cash proceeds net of the tax cost. The charitable deduction amount is determined using the fair market value, and the donor does not recognize the gain on the appreciation.
Utilize a Home Equity Loan
Interest on certain home equity loans or lines of credit can be tax deductible. Consider this if you need to finance significant purchases, such as a vehicle. For certain taxpayers, the alternative minimum tax (AMT) eliminates this deduction’s tax benefit. L. Porter Roberts, Jr., CPA, and Matthew S. Smith, CPA, CFE, are with the Medical Services Group of Barr, Anderson & Roberts, PSC, in Lexington, KY. If you would like more information, they can be reached via email at lproberts@barcpa.com and msmith@barcpa. com and via telephone at 859-268-1040. ◆ ISSUE#89 9
Q&A
Lexington Clinic Becomes Only AAAHC Accredited Medical Group Practice in Kentucky MD-UPDATE sat down with Dr. Robert L. Bratton, chief medical officer, and Mr. Tom Thomas, senior director of quality and performance improvement, to discuss the AAAHC accreditation recently awarded to the Lexington Clinic physician group. MD UPDATE: Dr. Bratton and Mr. Thomas, can you describe the significance of the Accreditation Association for Ambulatory Health Care (AAAHC) accreditation for the Lexington Clinic physician group? BRATTON: Lexington Clinic provides the highest quality of care to our patients, and AAAHC accreditation allowed us to compare all aspects of care to national benchmarks. It was not about putting a banner on the building; it is about providing excellent care to our patients. THOMAS: The accreditation brings a great sense of pride to the employees, staff, and physicians at Lexington Clinic. AAAHC collects the best standards and practices for medicine from the CDC, Best Practices, HIPAA, and OSHA. Through the effort and dedication of our team, we have achieved this recognition. BRATTON: Similar to Joint Commission accreditation for hospitals, AAAHC is the governing body for ambulatory care in the multi-specialty clinic setting. THOMAS: Another reason for choosing this type of accreditation is that the AAAHC reviews independent physician groups, like Lexington Clinic. Tell us about the AAAHC process at Lexington Clinic. BRATTON: Preparations began in 2009 with a three-pronged process first focused on patient and employee satisfaction. The second prong measured quality indicators 10 MD-UPDATE
“Lexington Clinic is well suited for the physician uninterested in hospital-employed practices,” Robert L. Bratton, MD, Chief Medical Officer, Lexington Clinic.
against national benchmarks. The third prong involved validation, and this is the AAAHC accreditation. When Tom joined the team in 2012, he infused enthusiasm and focus to drive Lexington Clinic toward our goal, as did Dr. W. Ben Kibler, the Physician Champion in the process. Describe the role of the Physician Champion. BRATTON: We needed a leader. A physician that was actively seeing patients to understand the commitment required for the AAAHC accreditation process and one that could foster buy-in and acceptance with colleagues was essential. Dr. Kibler is a world-renowned orthopedic surgeon and has been with Lexington Clinic for more than 37 years. He is well respected by the other physicians and staff and his leadership was instrumental in achieving the goal. THOMAS: A key component of preparation was internal communication. The preparation and implementation were rigorous, and it was important that all team members be committed to these efforts to not only achieve the accreditation, but
PHOTOGRAPH BY STEPHANIE NORTHERN, LEXINGTON CLINIC
“The accreditation brings a great sense of pride to the employees, staff, and physicians at Lexington Clinic,” Tom Thomas, Lexington Clinic, senior director of quality and performance improvement.
to prepare the organization for the future. AAAHC provided our team with a handbook addressing all areas of care and Dr. Kibler formed a committee around each area, whether facilities and environment, safety, and quality. There were more than 600 standards addressed. Multiple visits to each site for mock surveys further ensured team readiness. Is Lexington Clinic the only physician group in Kentucky with AAAHC accreditation? THOMAS: That is correct. There are ambulatory surgical centers and dental offices, but Lexington Clinic is the only physician group in Kentucky with AAAHC accreditation. The Lexington Clinic Surgery Center already has AAAHC Accreditation, what does the physician group accreditation add? THOMAS: The surgery center receiving accreditation was a terrific precursor to the physician group earning the accreditation.
We think of ourselves as a team and when standardization is addressed, it is important that every department and every specialty be involved in the process. Lexington Clinic is a team. BRATTON: There’s another side to this question. As insurance companies move toward new reimbursement models, the companies evaluate the quality of care provided to patients. The AAAHC accreditation is recognized as a symbol of quality care.
in their respective area. Lexington Clinic is one of the largest and oldest physician-owned practices in Kentucky. (Editor’s note: Lexington Clinic was founded in 1920) BRATTON: One of the very unique points of difference for Lexington Clinic is that our board is comprised of ten physicians, making us wholly physician-owned and operated.
Did the AAAHC survey team find any areas for improvement? THOMAS: There is always room for improvement. The process allowed us to immediately address any areas needing further attention, and our team was very proactive and did extremely well.
In the current health care model, how does AAAHC accreditation impact you? THOMAS: Navigating the everchanging healthcare environment independently can be challenging. However, an accrediting body like AAAHC stays current with the constantly changing standards and practices in healthcare and allows us to manage those changes into the future as well.
“State-of-the-art” and “quality care” are broadly used terms. Can you be more specific about how “quality care” is implemented here on a daily basis? BRATTON: It comes down to the care of our patients and the patient experience. There are many government quality initiatives and benchmarks to which we can compare ourselves, but it’s not about recording numbers, it’s about how we care for patients and if they receive positive outcomes. THOMAS: It’s not just about taking care of the sick patients. It’s also preventative medicine. How well are we doing to keep people from becoming ill? Can you give me a sense of patient volume at Lexington Clinic? BRATTON: Lexington Clinic has more than 2000 patient visits per day and those
patients are seen by our more than 200 providers at 35 locations across Central and Southeastern Kentucky. Most of the care is in Fayette County, and we have offices in areas such as Nicholasville, Danville, Richmond, Somerset and Frankfort as well. What does a three-year accreditation cover? Is more growth planned? THOMAS: Lexington Clinic will continue BRATTON: Our associate plan is very to offer the best patient care at all times. As successful and has attracted highly talented part of our accreditation, AAAHC can visit groups. Kentucky Ear, Nose and Throat our sites for an unscheduled evaluation at and Commonwealth Urology have joined any time. It is important that we continue to Lexington Clinic as associate practices, as maintain the standards and processes implewell as other smaller groups. Lexington mented during the accreditation process. Clinic is well suited for the physician uninBRATTON: Simply put, AAAHC accrediterested in hospital-employed practices. tation aligns Lexington Clinic with the goals THOMAS: It is very difficult for physi- of the patient, the goals of the payer, and the cians in private practice to stand alone. The goals of the government. Lexington Clinic size and offerings of our group enables those in a better position by achieving this kind practices to become a part of the Lexington of national benchmark, and our focus can Clinic system while continuing to deliver care continue to be on quality patient care. ◆
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ISSUE#89 11
COVER STORY
GAME CHANGER Dr. Jason Chesney discusses patients on clinical trials with Oncology Nurse Clinician Ernie Schnell, RN.
Dr. Jason Chesney and the U of L Brown Cancer Center, a part of KentuckyOne Health, are the first in the region to offer a new class of drugs that is prolonging life in stage 4 melanoma patients BY JENNIFER S. NEWTON
PHOTOGRAPHY BY BRIAN BOHANNON 12 MD-UPDATE
University of Louisville’s (U of L) James Graham Brown Cancer Center Deputy Director Jason A. Chesney, MD, PhD, has one imperative message when it comes to stage 4 cancer: DON’T WAIT. Get to a clinical trial center for a second opinion. It could be the difference between life and death. “We have a huge problem in Kentucky with health care access in general,” says Chesney. “It is so important to get the word out to patients with stage 4 cancer that they should not be treated at a community hospital or community oncology center that doesn’t have a very big, broad clinical trials program … Don’t let your doctor treat you with an FDA-approved drug that hasn’t been shown to improve survival and that by definition will disqualify you from some clinical trials.” The evidence is pretty compelling. With an average of 150 LOUISVILLE
trials going on at any one time, the Brown Cancer Center, part of KentuckyOne Health, not only can offer patients access to therapies before they are FDA approved, they also have early access to newly FDA-approved treatments. Case in point: two new classes of drugs for stage 4 melanoma patients, which are doing something no treatment has done before – prolonging life.
to improvements in quality of life,” says Chesney. Instead, by activating the immune system, ipilimumab prevents tumors from growing and from causing death. While a 17 percent survival rate is phenomenal compared to zero, it still leaves 83 percent of end-stage melanoma patients facing an eight-month median survival rate.
The Scoreboard
PEMBROLIZUMAB IS A GAME CHANGER. NO PATIENT WITH STAGE 4 MELANOMA SHOULD DIE WITHOUT GETTING THIS DRUG.
In the US, 70,000 patients are diagnosed with melanoma each year. Approximately 9,000 to 10,000 of those die from it. “Until five or six years ago, the only treatments available [for stage 4 melanoma] would palliate patients but not cure them,” says Chesney. “There were no standard FDA-approved drugs that had been shown in a randomized trial to improve overall survival.” In 2011, that all began to change when ipilimumab (trade name Yervoy®) was FDA approved. The Brown Cancer Center was part of the phase 1/2 dose-escalation trial from 2005-2007. “This was the first agent in the history of humankind to show an improvement in overall survival in stage 4 melanoma patients,” says Chesney. Ipilimumab works by activating the immune system. It is an antibody that blocks the immune checkpoint protein CTLA-4 (cytotoxic T-lymphocyte-associated protein 4), preventing cancer cells from turning off the immune system. “In 20 percent of patients, they have durable, objective, long-term responses where tumors aren’t growing anymore or are shrinking. Seventeen percent of patients are alive after seven years if they’ve gotten that drug,” says Chesney. As an immunotherapy, ipilimumab is an entirely new class of drugs. “It doesn’t work like the typical class of chemotherapy drugs work, which work by targeting DNA and causing tumors to shrink. It turns out that doesn’t necessarily lead to improvements in survival and doesn’t necessarily lead
Fortunately, immunotherapy is just beginning to assert its potential.
The MVP of Immune Checkpoint Protein Inhibitors
Multiple pharmaceutical companies are developing new immunotherapies that target other immune checkpoint proteins. One such checkpoint is PD-1 (programmed death 1). Like CTLA-4, PD-I stimulates the immune system against tumors. What is unique about PD-1 is it is accompanied by a ligand that binds it to T-cells, called PD-L1 (programmed death-ligand 1). Chesney describes PD-L1 as “the foot on the brake” of the immune system. Pharmaceutical companies are now developing antibodies
against both PD-1 and PD-L1. “Up to this point, we have very strong data in melanoma, renal cell carcinoma, and lung cancer that 20 to 30 percent patients are having a dramatic response to this type of agent,” says Chesney. The two drugs at the forefront of this class are nivolumab (Opdivo®) by BristolMyers Squibb and pembrolizumab (Keytruda®) by Merck. Bristol-Myers Squibb is currently seeking FDA approval for nivolumab. The Brown Cancer Center is participating in a phase 1/2 clinical trial testing nivolumab in combination with ipilimumab for melanoma patients, as well as a phase IIIb/IV trial testing nivolumab in advanced lung cancer patients. The second leading drug in the class of PD-1 inhibitors – pembrolizumab (Keytruda) – is notable because it received accelerated FDA approval on September 4, 2014 due to its compelling preliminary survival data, becoming the first drug approved in the PD-1 class. “This drug is a monotherapy in a second-line setting, after ipilimumab, for example,” says Chesney. “It has approximately a 30 to 40 percent response rate.” Pembrolizumab is administered as a onehour infusion, once every three weeks. After
Medical Oncologists Dr. Jason Chesney and Dr. Beth Riley discuss the development of PFK-158 and its activity against breast cancer cells with Brown Cancer Center patient Barbara Baumgardner. An upcoming clinical trial will test PFK-158 with the anti-estrogen fulvestrant in breast cancer patients. ISSUE#89 13
COVER STORY four three-week cycles, a scan is performed to determine the patient’s response. If the tumors are shrinking, patients are given the choice to continue. At this point, physicians do not know how long the maintenance phase should last in order to maintain results and minimize side effects. Toxicity for pembrolizumab is lower than that of ipilimumab, which can cause auto-immunities such as autoimmune colitis, autoimmune dermatitis, autoimmune hepatitis, and autoimmune hypothesis. With PD-1 inhibitors like pembrolizumab, the most significant side effect is pneumonitis, which occurs in four percent of patients and is treated with oral steroids. While there is no survival data yet because pembrolizumab was fast-tracked, Chesney says, “What we’re seeing right now with response rates is they’re durable, and they’re ongoing and progressively getting better.” He cites the response rate of ipilimumab, which is 15 percent, while the seven-year survival rate is 17 percent. With a 30 to 40 percent response rate for pembrolizumab, he is hopeful the five-year
Dr. Jason Chesney talks with IV Pharmacy Tech Julie Ray in the Brown Cancer Center research pharmacy, where test agents are prepared, prior to infusion into advanced cancer patients.
survival rate will be 30 to 40 percent. “I’m very hopeful that combining ipilimumab with the other PD-1 that’s not approved yet, nivolumab, that we’re going to see even higher response rates and more durable survival improvements,” he adds.
The Early Lead Advantage
U of L’s Brown Cancer Center was again a 14 MD-UPDATE
major center for the pembrolizumab trial, allowing its patients early access to the drug. “Because we had so many patients getting the drug as part of a trial, Merck made sure that we were one of the first sites in the nation to have the FDA-approved commercial product available for our patients. This means that patients from Kentucky and Indiana don’t have to travel to Nashville, Texas, or one of the coasts to receive this drug,” says Chesney. It is therapies like these that make access to a clinical trial center such as U of L or the University of Kentucky (UK) so crucial to the treatment of stage 4 cancers, Chesney contends, particularly when it comes to melanoma. U of L is the only center in the region with a major multidisciplinary melanoma clinic. “We became the only site for melanoma patients in the region if they want to get this drug that’s at least three times more effective than any FDA-approved drug for melanoma,” he says. However, Chesney is hopeful that over the next six months the drug will proliferate to UK and other centers in the community. “This drug is a game changer. No patient that has stage 4 melanoma that has progressed after the standard therapies should die without getting this drug,” he says. And melanoma is just the starting point. According to Chesney, “This class of drugs and pembrolizumab is not only effective in melanoma but has been proven effective in multiple types of cancer clinically and even better in combination with other immunotherapy. It’s an inflection point in our ability
to handle cancer.” In addition to testing new immunotherapeutics for cancer patients, the Brown Cancer Center is also at the forefront of early stage drug discovery and has a rich pipeline of drugs entering early phase 1 trials. For example, one such drug, PFK-158, was developed in Chesney’s laboratory and is currently undergoing phase 1 trial testing at UofL and Georgetown University in Washington, D.C., for all types of human cancer. Multiple phase 1/2 trials combining PFK-158 with FDA-approved targeted agents for lung cancer, melanoma, renal cell carcinoma, colon cancer, pancreatic cancer, and leukemia are currently in development. “This drug and phase 1 trial are first-in-class and first-in-human and were conceived and developed at the Brown Cancer Center … Cancer patients are already benefiting through their participation in our trials of these novel agents,” Chesney says.◆
Jason A. Chesney, MD, PhD Medical Oncology / Hematology Deputy Director of the James Graham Brown Cancer Center 529 S. Jackson Street Louisville, KY 40202 502.562.4673 (HOPE)
SPECIAL SECTION ONCOLOGY
Improving Access to Better Breast Cancer Care in Kentucky Demands Challenging The Status Quo BY ANTHONY E. DRAGUN, MD “It is difficult to get a man to understand something when his salary depends on his not understanding it.” — Upton Sinclair Appropriate management of early stage breast cancer involves choosing breastconserving therapy (BCT) — lumpectomy followed by radiotherapy — or mastectomy. Data from multiple studies demonstrate equivalent cure rates for these two approaches, and thus BCT is preferred by the overwhelming majority of patients. The challenge has been to ensure access to radiotherapy (RT), as it improves local control and long-term survival for nearly all BCT patients. In the US, reports regarding RT application contain estimations that vary widely (range: 65-95 percent). Analyses of national database studies indicate that the lowest relative rates of RT exist in sparsely populated regions, especially the Southeast. How big is this problem in Kentucky? In 2009, data analyzed for 12,000 women who underwent BCT between 1998-2007 showed the rate of RT to be a dismal 66 percent1. Not surprisingly, the rate was even lower for elderly, rural, minority, and uninsured patients. Why is providing RT such a challenge? Because RT is the only oncology service that has traditionally required a commitment to daily treatments over the course of sixto-seven weeks. For patients who depend on limited public transportation options, or who travel up to 50 miles oneway for each treatment, RT is unfeasible even for the well-insured due to extraordinary cost borne directly by patients (transportation, time away from home and work). Unfortunately in the US, development of alternative RT strategies is hindered by the mal-incentives of our fee-for-service system. For RT, payors reimburse providers based on the number of treatments rather LOUISVILLE
Anthony E. Dragun, MD, is associate professor of radiation oncology for the University of Louisville School of Medicine.
than complexity, quality, or diagnosis. In countries with centralized health care, such as the United Kingdom and Canada, physicians have long used ”hypofractionated” radiotherapy (HFRT), which halves the total dose and the number of treatments2-4. Long-term data from trials involving 7,000 patients show equivalent results, enabling shorter total treatment time, enhanced convenience, and lower cost. Although three weeks of daily HFRT is a significant improvement over the sixto-seven week traditional RT course, the daily therapy requirement continues to present barriers to underserved populations in regions with scarce oncology resources. The favorable results from HFRT trials have emboldened our British colleagues to “push the limits” of HFRT by investigating onceweekly regimens4. Early Phase III results show toxicity, cosmetic outcome, and efficacy of this approach to be comparable to traditional RT. Given these promising results and our patients’ needs, in 2011, the James Graham Brown Cancer Center became the first insti-
tution in the US to offer a Phase II trial of once-weekly HFRT for women with early breast cancer6. To date, we have enrolled over 150 patients, with a goal of accruing 250. Two interim analyses showed that the regimen has fewer side effects and comparable cosmetic outcomes to traditional RT. In terms of costs, once-weekly HFRT is much less expensive ($2,901) than daily HFRT ($8,567) or traditional RT ($10,815). Most importantly, our patients have been very pleased with the convenience of this approach, and many have traveled over 100 miles to participate. Most have said that, had it not been for this trial, they would have either have risked going without RT or have had a mastectomy. Due to its popularity, we will roll out additional accrual sites in the Commonwealth through the KentuckyOne Health network in the coming months. As data matures we are optimistic that once-weekly HRT will eventually become a standard option for the treatment of breast cancer. Disparities in the provision of breast cancer care represent microcosms of the PHOTO COURTESY OF UOF L
ISSUE#89 15
SPECIAL SECTION ONCOLOGY
widening “health care gap” between wealthy and poor, urban and rural populations. Incentive programs that improve quality and access must also be pragmatic and cost-effective. Ultimately, oncologists must educate fellow physicians to expand the use of more patient-centric alternatives to the status quo. Right now, once-weekly HFRT should only be delivered on a clinical trial, however daily HFRT is a step in the right direction and its use should be widely implemented as a crucial component of the next generation of breast cancer therapy.
FOR FURTHER READING
Dragun AE, Quillo AR, Riley EC, et al. A phase 2 trial of
Dragun AE, Huang B, Tucker TC, Spanos WJ. Disparities in the application of adjuvant radiotherapy after breast-
of acute toxicity, feasibility, and patient satisfaction. Int J
conserving surgery for early stage breast cancer: Impact on
Rad Oncol Biol Phys. 2013; 85(3):e123-8. ◆
overall survival. Cancer. 2011 Jun 15;117(12):2590-8. Whelan T, Pignol JP, Levine M, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362:513-20. Haviland JS, Owen JR, Agrawal RK, et al. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 2013; 14: 1086-94. Yarnold J, Bentzen SM, Coles C, et al. Hypofractionated
Anthony E. Dragun, MD, is associate professor of radiation oncology for the University of Louisville School of Medicine and James Graham Brown Cancer Center and a radiation oncologist with University of Louisville Physicians. He recently presented his trial findings at the Breast Cancer Symposium 2014 in San Francisco, California.
once-weekly hypofractionated breast irradiation: First report
whole-breast radiotherapy for women with early breast
Anthony E. Dragun, MD Radiation Oncology
cancer: Myths and realities. Int J Radiat Oncol Biol Phys. 2011;79(1):1-9. “ASTRO releases list of five radiation oncology treatments to question as part of national Choosing Wisely campaign.” Choosing Wisely. ASTRO, 23 Sept. 2013. Web. 1 June 2014. <http://www.choosingwisely.org/ astro-releases-list-of-five-radiation-oncology-treatments-to-
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SPECIAL SECTION ONCOLOGY
Targeting Tumors and More
Norton Cancer Institute – Downtown introduces high dose radiation for the betterment of patients BY JENNIFER S. NEWTON
In October 2011, MD-UPDATE featured the new Norton Cancer Institute – Downtown, an innovative facility designed to simultaneously treat the medical and psychosocial needs of patients in a wellness-centered atmosphere. Proving to be more than just a uniquely attractive facility, Norton Cancer Institute has adopted technology and procedures that are changing the way patients experience radiation therapy. “Since our center opened, we have pioneered the use of frameless radiosurgery for brain lesions, and we’ve done over 250 cases,” says Aaron Spalding, MD, PhD, adult and pediatric radiation oncologist. “The main impact has been that in addition to treating malignant brain tumors, we’re now better able to treat tumors near critical structures,” all while utilizing noninvasive techniques and without requiring pins screwed into a patient’s head. From that, Spalding and his colleagues have been able to expand treatment to nontumor applications for arterial venous malformations (AVMs) and trigeminal neuralgia. “We are able to deliver very high dose radiation about the size of the tip of a sewing needle really close to the brain,” says Spalding. The Institute has utilized this technique to treat 40 AVM patients and has improved trigeminal neuralgia treatment to include minimal sedation in a 60-minute outpatient procedure. Spalding says their results have been as good, if not better, than with traditional head frames. Their data have been presented at the International Society for Radiosurgery (ISRS) most recent meeting in Toronto. LOUISVILLE
Aaron Spalding, MD, PhD, is an adult and pediatric radiation oncologist with Norton Cancer Institute – Downtown and co-director of the Institute’s Brain Tumor Center.
Beyond the Brain
Building on their frameless radiosurgery experience, Norton Cancer Institute – Downtown is putting high-dose radiation to use in areas beyond the brain, including the liver, pancreas, and prostate. “Now that we’ve become more familiar with using high-dose radiation inside the skull, we’ve also pioneered locally the use of body radiosurgery or stereotactic ablative body radiotherapy (SABR),” says Spalding. SABR’s biggest advantage is that it reduces the number of radiation treatments from upwards of 44 to five or fewer. For patients, that means one week of treatment rather than one to two months. Additionally, the use of SABR can prevent invasive surgery in some cases, and it reduces the incidence of side effects such as fatigue and pituitary dysfunction. Spalding adds the cure rates with SABR are equal to, or in some cases higher than, traditional radiation therapy. One tool that enhances SABR’s precision in the prostate is the Calypso® 4D Localization System. “Calypso is a small transponder around the size of an uncooked grain of rice,” says Spalding. The transponders are implanted in the prostate. During radiation therapy, the transponders send out radiofrequency waves 60 times a second to allow physicians to localize the prostate in real time and deliver the most accurate treatment. Norton has been utilizing Calypso since January 2014 with both traditional radiotherapy and SABR patients.
Beyond external beam therapies, for the past 12 months Norton patients with metastatic prostate cancer have had access to a new treatment option – Xofigo®. An injectable medication, “Xofigo allows patients to have treatments for bone metastases with CONTINUES ON PAGE 19
TARGETED TREATMENTS FOR CANCER Norton Cancer Institute Radiation Centers Call (502) 629-HOPE to refer a patient. Learn more at NortonCancerInstitute.com.
PHOTOGRAPH BY BRIAN BOHANNON
ISSUE#89 17
SPECIAL SECTION ONCOLOGY
Practicing Prevention
Dr. Ifeoma Roseline Okeke puts cancer prevention into practice with a High Risk Breast Clinic at the Floyd Memorial Cancer Center of Indiana BY JENNIFER S. NEWTON Last November, MD-UPDATE’s Oncology Issue (#81) featured an article with Ifeoma Roseline Okeke, MD, board-certified medical oncologist and hematologist with Floyd Memorial’s Cancer Center of Indiana and a proponent of breast cancer prevention. Okeke set a goal to create a breast cancer prevention clinic, and in March of this year, that goal became a reality when Okeke instituted the High Risk Breast NEW ALBANY, IN
do a full risk assessment, including family history and medical history, review mammogram reports, and perform a physical breast exam. Based on their family history, we decide if genetic testing is a recommendation for them,” says Okeke. She also does a personal risk assessment for all patients and, in addition to family history, considers factors such as prior multiple breast biopsies, breast density, and hormone replace-
Center now offers a more comprehensive genetic analysis that goes beyond BRCA1 and BRCA2. My Risk comprehensive genetic testing evaluates for 21 genes, including not just those for breast but also for other cancers, such as Lynch syndrome for colon cancer. “Many patients have overlapping cancer syndromes in their families, and sometimes it is difficult to determine what genes may be affected,” says Okeke.
A Four-Tiered Approach
Dr. Ifeoma Roseline Okeke is the director of the Breast Cancer Program at Floyd Memorial’s Cancer Center of Indiana.
Clinic at the Cancer Center of Indiana. The clinic offers a novel approach to preventive breast care, offering thorough risk assessment, medical imaging, clinical exams, genetic testing, counseling, and cancer prevention recommendations. Patients can access the clinic one of two ways – either through physician-referral or self-referral. The first step in the clinic process is a full consultation with Okeke herself. “We 18 MD-UPDATE
PHOTOGRAPH BY GIL DUNN
ment therapy that may contribute to risk for breast cancer. Patients are deemed high risk if they screen positive for a genetic mutation or if they screen negative but score high on the personal risk assessment, which means, “They have more than a 20 percent lifetime risk for developing breast cancer,” she says. In terms of genetic testing, the Cancer
Once patients are determined to be high risk, Okeke works with each woman to determine their best preventive course of action. The recommendations follow a four-tiered approach: lifestyle modifications, prophylactic surgery, chemoprevention, and aggressive screening. “Everybody gets lifestyle modification education – stop smoking, limit alcohol, avoid post-menopausal weight gain, and avoid hormone replacement therapy, especially combined estrogens and progesterone,” says Okeke. These patients also have access to a multidisciplinary team of specialists, including medical oncologists, plastic surgeons, general surgeons, psychiatrists, and radiologists. The most effective prevention is prophylactic surgery, although Okeke cautions this is a very personal decision and not one that is recommended in all cases. BRCA 1 and BRCA 2 mutations carry up to an 84 percent lifetime risk for breast cancer and a 15 to 50 percent risk of ovarian cancer. Prophylactic mastectomy reduces breast cancer risk by approximately 90 percent, and prophylactic oophorectomy reduces breast cancer risk by up to 50 percent. Although hysterectomy is not routinely performed in patients with BRCA mutations, a growing number of uterine cancers have been detected in some BRCA2 families. The next level of care is chemoprevention, which reduces cancer risk by 50 to 60 percent, and is utilized in both those who screen positive for genetic mutations
and those who screen negative but are deemed high risk. Current chemoprevention medications include tamoxifen and raloxifene (Evista®), which are both FDAapproved, and exemestane and anastrazole (Arimidex®), which are not yet FDAapproved but have been shown to be effective. For patients who do not have a genetic mutation or who simply do not qualify for genetic testing but are considered high risk, Okeke recommends aggressive screenings with breast MRIs and mammograms every year and clinical breast exams every six months. These women are also encouraged to perform monthly self-breast exams.
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Getting Results
So far, the High Risk Breast Clinic has screened 95 patients. They have identified four patients with genetic mutations and three patients with breast cancer, who were
WE ARE SO USED TO TREATING BREAST CANCER. I THINK THE PARADIGM IS SHIFTING TO PREVENTING CANCER. at high risk but did not have the mutation. Thanks to the prevention program, all three cancers were found at stage 1. Because the Center now tests for 21 gene mutations, they are looking at developing other specialty prevention clinics, the next of which may be a GI cancer prevention clinic. “We are so used to treating breast cancer. I think the paradigm is shifting to preventing cancer, but a lot of us are not on board yet,” says Okeke. “It is important for women to realize they can be their own health care advocates. They need to ask about cancer risk just like they ask about body weight, BMI, and cholesterol. We can educate women through community outreach programs. My goal is eventually for everybody to be on-board.” ◆
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graphically comprehensive but specialized care.” For example, weekly breast cancer conferences are teleconferenced across all Norton locations, so that women may receive care wherever they need it. Spalding says the next step will probably be an integrative multispecialty breast clinic. According to Spalding, Norton sees “more cancer than anyone else in the state.” That large volume, coupled with advanced techniques, a uniquely designed facility, an active research portfolio, and an institutional affiliation agreement with the University of Kentucky round out a comprehensive scope of cancer care. Ultimately, for Spalding, those elements converge to target two of the most fundamental questions in cancer care in Kentucky: “How do we become better educators of our patients?” and, “How do we get patients where they need to be no matter where they live in the state?” ◆
Targeting Tumors and More
Norton Cancer Institute – Downtown introduces high dose radiation for the betterment of patients CONTINUED FROM PAGE 17
very low side effects, much lower than chemo and much better tolerated. It allows us to prevent not only death but also bone fractures from prostate cancer,” says Spalding.
Specialized Services
Norton Cancer Institute – Downtown includes multidisciplinary clinics for brain tumors, sarcoma, and lung cancer. With the new Norton Women’s and Kosair Children’s Hospital developing on the former Norton Suburban Campus in Louisville’s east end, many of the women’s health services are centered there. However, Spalding says the program has been designed to be “geo-
ISSUE#89 19
SPECIAL SECTION ONCOLOGY
Relationship Driven
Oncologist Rick C. Myhand, MD, brings vast experience and a desire to cultivate relationships to Georgetown Community Hospital BY TIM CORKRAN Rick C. Myhand, MD, knew he wanted to be an oncologist two months into his first clinical rotation. It was not, however, the allure of innovative treatment technologies or a fascination with tumor growth that compelled him so certainly. Rather, his path was laid out by a single patient with whom he bonded during his internal medicine rotation and the “Thank you” card the patient’s wife sent Myhand after his passing. Anticipating such relationships with future cancer sufferers placed Myhand in his field. His path has not been direct, but his destination was clear: “One of my goals was always to be a community oncologist. I like direct patient care the most,” says Myhand. GEORGETOWN, KY
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Since January 2013, cancer patients in Georgetown, Ky., have had access to this committed and compassionate physician. The area’s residents have also had access to the wisdom and competence gleaned from Myhand’s 23 years in the field, not the least of which included stints as chief of the Hematology/ Oncology Department at Walter Reed Army Medical Center, Brooke Army Medical Center and later, the San Antonio Military Medical Center. As he rose through the medical ranks, Myhand continued to see patients, and ultimately concluded, “The administrative stuff was fun, but what I enjoyed the most was seeing patients.”
From Military to Community Hospital
Myhand was accepted to and graduated from the US Military Academy at West Point and attended medical school courtesy of the Army. He performed 21 years of service, primarily in Washington, DC, and San Antonio. Both of these military medical centers are also training facilities, therefore Myhand spent considerable time training oncologists and hematologists. While in this academic role, he served as faculty, assistant program director, and later, program director of the Hematology/ Oncology Fellowship training program in San Antonio. While stationed there, he volunteered in 2007 to deploy to Iraq with a Combat Support Hospital in the capacity of an internal medicine physician. Following this, Myhand had the option of pursuing a civilian career as a medical administrator but instead chose private practice at a community hospital. The move to Georgetown was carefully considered by Myhand and his wife Nikki. With much of their family in the eastern half of the US, central Kentucky made sense. “Georgetown seemed like the ideal place,” he recalls. “It was a smaller town but not too small, and its proximity to Lexington was a big advantage.” He values being near UK’s Markey Cancer Center (MCC) and has an affiliation with MCC that allows him to serve his patients better. “Cancer patients need more than just medical oncologists, they need surgical and radiation oncologists, tumor imaging radiologists, etc.,” he notes. Georgetown Community Hospital (GCH) has been all that Myhand hoped for, and the setting complements the nature of oncology practice. For him, “When you are dealing with cancer patients, all the superficial things that we walk Dr. Rick Myhand draws on around with, that separate his 21 years of military service for his role as sole us, go away. You really get oncologist at Georgetown to know patients, and they really get to know you.” Community Hospital. PHOTOGRAPH BY GIL DUNN
Advanced Cancer Care Close to Home The relationships that come so easily under these conditions are further facilitated by the community hospital setting. As the sole oncologist at GCH, Myhand follows most of his patients throughout their cancer treatment and then sees them for their annual check-ups. His patients live in his town, or in the rural areas nearby, and may even be his neighbors’ relatives.
Familiar Patients and a Dynamic Field
Myhand’s patient population is solely adults, many of whom are over 60. This mirrors the population he served in the military. Military retirees (with 20 or more years of service) and their family members are eligible for cancer treatment at the major military hospitals – Walter Reed, San Antonio – and tend to go there rather than to their local VA. Myhand saw many of the World War II generation early in his career at these facilities. Like those patients, his current patients’ most common needs are related to breast, colorectal, prostate, and lung cancers. He also sees patients for lymphoma, multiple myelomas, and as a hematologist, blood disorders. Myhand notes that cancer treatment has changed dramatically over the last eight to 10 years. He sees the sum of that making it “much less harsh today than in the past.” The implications of this are multiple: patients are tolerating treatment better, and their quality of life during treatment is improved. Finally, relatively healthy elderly people stand a better chance of being able to take advantage of treatments. A 70-year-old cancer patient need not succumb to the disease, when newer, gentler treatments can give them more years with their family. He adds that geriatric oncology is an emerging field, and
many elderly patients are more likely to die of old age than to die of their cancer. Advances in personalized oncology care “have really been exploding over that time period,” he notes. There is a great deal of biological heterogeneity in cancer cells, so two patients with the same diagnosis, receiving the same treatment, can have totally different outcomes. Tumor profiling with molecular techniques, particularly looking for so-called driver mutations, are illuminating how to treat those patients individually. This process, which some call “interrogating the tumor,” helps physicians determine what makes an individual cancer more susceptible to a course of treatment and then come up with the best treatment plan for that individual patient. Myhand is excited about such processes that are “getting even more elegant on a molecular level now.” Being the sole oncologist/hematologist in a community hospital is no step down for Myhand, rather the realization of a personal goal predestined by his experience with that cancer patient early in his medical school rotations. The gravity of a cancer diagnosis and the subsequent treatment makes for a special patientphysician bond. “What I have learned is that patients do not expect miracles from you, but they want to know that someone really cares,” says Myhand. Rick Myhand, MD, could be anywhere in the oncology world, but he wants to be the cancer doctor for a tight community. He wants to see patients who will return to him through the course of their treatments, and to help keep families intact for as long as possible. He puts it simply, “I could not imagine being another type of physician.” And, yes, he still has that 30 year-old “Thank you” card. ◆
I HAVE LEARNED THAT PATIENTS DO NOT EXPECT MIRACLES BUT DO WANT TO KNOW SOMEONE REALLY CARES.
Board-certified in Internal Medicine and Medical Oncology/ Hematology, Dr. Rickey Myhand brings vast experience and expertise to our community. He is specially trained in the diagnosis and treatment of a variety of cancers and blood disorders. Dr. Myhand works closely with patients and their families to develop treatment plans that are designed to meet each patient’s unique needs. For more information or to schedule an appointment, call (502) 868-5603.
1140 Lexington Road, Suite 202 Georgetown, KY 40324 www.georgetowncommunityhospital.com
ISSUE#89 21
SPECIAL SECTION ONCOLOGY
Noted Anesthesiologist is First in Region to Offer Pain Relief in Metastatic Spinal Tumors Radiofrequency ablation and cement infusion stabilize the vertebral body against possible fracture BY SUSAN SMITH
William O. Witt, MD, medical director of the Cardinal Hill Pain Institute, is among a select group of physicians throughout the country, and the first in central and eastern Kentucky to offer Targeted Radiofrequency Ablation™ (t-RFA), a minimally invasive palliative treatment for patients with painful metastatic vertebral body tumors. Of the more than 1.6 million new cancer cases that will be identified this year, it is estimated that 30 to 40 percent of patients will develop metastatic spinal tumors.1 Metastatic tumors within the spine can lead to intense pain and impaired mobility as bone weakens. Often tumors in the spine cause pain with or without a fracture due to the inflamma- William O. Witt, MD, medical tion caused by the director and founder Cardinal tumor that frequently Hill Pain Institute; chairman affects the spinal nerves emeritus, Anesthesiology/ or the spinal cord as University of Kentucky; well. Witt recalls treat- professor emeritus, Anesthesiology, Neurosurgery ing a patient with mul- and Hematology-Oncology; tiple myeloma with founding director emeritus, Pain fractures due to osteoporosis. four separate epidural Management Fellowship. This experience has led him catheters to control the to offer this new treatment for pain because the tumor had obstructed the pain caused by spinal tumors. For many epidural space. Witt contends that opioids years, patients with metastatic spinal tumors alone cannot effectively treat all cancer- have been effectively treated with radiation related pain, particularly when there is a therapy, and this is still an excellent option. neuropathic component, as often occurs However, t-RFA now offers an alternative with spinal metastases. He says that since by delivering radiofrequency energy in the completing his formal training in pain palliative treatment of these tumors with a management in 1978, controlling the pain single outpatient procedure. This provides due to spinal metastases has been one of the cancer patients with rapid pain relief while more challenging procedures. allowing them to continue systemic therapy, Witt has extensive experience in treat- such as chemotherapy or hormone therapy, ing chronic pain of all types including to treat their primary cancer. T-RFA still the pain caused by vertebral compression allows patients to receive focal radiation LEXINGTON
22 MD-UPDATE
PHOTO COURTESY DR. WILLIAM WITT
therapy if necessary. Because any tumor ablation can weaken the vertebral body, this new approach allows Witt to inject methyl methacrylate cement through the same needle to stabilize the bone and prevent a fracture once the tumor is ablated. T-RFA is typically an outpatient procedure that is performed through a small incision using sedation and local anesthesia. It takes, on average, 45 minutes, and the patient is usually released for home recovery and care within hours. A small steerable device allows Witt to target precisely where the device’s radiofrequency energy is delivered to heat and destroy the spinal tumor, minimizing damage to surrounding tissues and vital structures. In most cases, patients with pain associated with spinal tumors have experienced dramatic pain relief with a single treatment. A recently published multi-center study2 on the treatment of metastatic spinal lesions with this navigational radiofrequency ablation device showed fast and lasting relief from painful metastatic lesions: • 50 percent of patients reduced their pain medication. • Otherwise inaccessible lesions were treated. • It was an option for those who failed or could not undergo radiation therapy. • There was no disruption of other therapies and protocols the patients were receiving. • The further growth and canal extension of the treated tumor was arrested.
Tumors frequently metastasize into the medullary portion of the vertebral body.
Temperature-controlled radio frequency energy is delivered to produce necrosis of the metastatic tumor. IMAGES PROVIDED BY DFINE, INC.
T-RFA is performed by placing a steerable radio frequency probe under local anesthesia with sedation, through the pedicle and into the metastasis.
Once the metastatic tumor has been destroyed, methyl methacrylate cement may be introduced through the same cannula to stabilize the vertebral body.
• An increased quality of life was demonstrated. “T-RFA is a great advance in the palliative care options we offer our patients,” said Witt. “This new targeted therapy provides rapid relief from the debilitating effects of spinal tumors in the vertebrae without interrupting a patient’s current cancer treatment schedule. We are excited about the potential of this unique treatment option and the potential for significant benefit for our patients.” SEER Cancer Statistics Review, National Cancer Institute, Noone, et al. 2 Anchala, Irving, Hillen, Friedman, Georgy, Coldwell, Tran, Vrionis, Brook, & Jennings Pain Physician 17 (4). ◆
FOR PATIENT REFERRAL 859.367.7246 (859 FOR PAIN) FAX: 859.254.5715 2050 Versailles Rd Lexington KY 40504 www.cardinalhill.org www.docwow.com
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www.boonecreekcreamery.com • ed2@kycheese.com ISSUE#89 23
COMPLEMENTARY CARE
How to Heal the Pain of Estrangement Nothing can create more feelings of shame than to be rejected by your own children. One parent described it this way, “It’s like she died, only worse — my adult child lives here in town, but she won’t have anything to do with me — and places all the blame for the estrangement on me.” Even “nice kids” estrange themselves from their parents. Even “good parents” that have invested time, love, and money in attempting to help their children succeed and be happy may find that instead of the closeness they expected to enjoy with their adult children, they are excluded from their children’s lives. If you have patients whose adult children have cut them off, know that it can evoke powerful feelings of guilt, regret, confusion, anxiety, helplessness, and rage. But more than anything, the shame associated with being rejected by an adult child causes many parents to suffer in silence and isolation, believing that, “I must be a terrible person if my own child would reject me.” Estranged parents struggling at the sight of other people enjoying a good relationship with their adult children and worrying about, “What do I say when others ask me about my children or grandchildren?” may withdraw socially and come to dread holidays and birthdays. Because our identities are closely tied to our perceptions of ourselves as parents, a high percentage of estranged parents become depressed, some even suicidal, as a result of being cut off by their adult children. But they may be too ashamed to tell you what’s behind the physical or emotional symptoms you observe in the examination room. Joshua Coleman, psychologist and author of When Parents Hurt: Compassionate Strategies When You and Your Grown Child Don’t Get Along says, “We have also socialized [our children] to believe that they should prioritize their well-being, be assertive, and not let anything or anyone interfere with their happiness. Sadly, we didn’t realize that we would one day be one of the items on the menu that interferes with their happiness.” Although divorce and the negative influence of an ex-spouse is one of the most common reasons children estrange themselves LOUISVILLE
24 MD-UPDATE
from a parent, a difficult spouse that remains in the marriage can also alienate an adult child from the other parent. Other common contributors to estrangement temperaBY Jan Anderson, PsyD, LPCC are mental mismatches between a parent and child, a difficult son-in-law or daughter-in-law, and the child’s need for autonomy. Even some therapists contribute to an estrangement. Just as the causes of estrangement are complex, how to respond to this profoundly painful dilemma is not simple. Your patients may be struggling with questions such as: “Should I defend myself, explain myself, or just listen? Should I apologize for past mistakes? What’s the best way to make amends? How do I respond to my estranged child’s hostility and contempt? Requests for money?” As Coleman points out, “You can’t be a parent and not make mistakes. This does not mean that your mistakes are the reason for your estrangement or that you deserve it. But I have never seen a reconciliation happen without the parent at least being willing to look at their own part in why the adult child has created such a powerful form of distance between themselves and the parent.” If you have patients that are estranged from their adult children or if you are experiencing estrangement yourself, begin the healing process with three simple steps: Seek support. Healing from the psychological challenge of estrangement involves dealing with feelings of profound vulnerability. Shore up your psychological strength by seeking the support of those that understand estrangement and can help. If close friends and relatives don’t have the skills to help you or simply aren’t able to provide the degree of emotional support you need, seek professional help or join an online support group such as www.dailystrength.org/groups. Seek connection. Invest in people and
activities that can help you restore a sense of your identity as a person and meaning in your life. Seek forgiveness. Your child may not forgive you, but that doesn’t mean you aren’t deserving of forgiveness for your mistakes as a parent. Put the focus on learning to forgive yourself as you make amends for your mistakes. Dr. Jan Anderson is a licensed professional clinical counselor with a doctorate in clinical psychology. Her private practice includes over 15 years of experience counseling individuals, couples, and families. EDITOR’S NOTE: Dr. Jan Anderson presented Mindfulness: How to Focus Your Attention, Reduce Emotional Reactivity and Connect to an Inner Wisdom at the Kentucky Mental Health Counselors Association Annual Conference on November 6, 2014 at the Crowne Plaza in Louisville. ◆
COMPLEMENTARY CARE
LIVESTRONG at the YMCA The YMCA of Central Kentucky ologists from the and the LIVESTRONG Foundation offer LIVESTRONG health and wellness programming for cancer Foundation and survivors through the LIVESTRONG at the YMCA of the the YMCA program. The program is free USA. and open to anyone who has had a cancer One of the diagnosis. most unique Intended to offer hope and health, the aspects of the LIVESTRONG at the YMCA program is program is the designed to strengthen and support cancer diversity of the BY Dave Perterson survivors on the road to recovery after their participants – treatment regimen. This 12-week, small anyone with a group program is designed for adult cancer cancer diagnosis is invited to participate. survivors who have become deconditioned Prior to beginning the program, paror chronically fatigued from their treat- ticipants meet with YMCA staff to discuss ment and the disease itself. Participants their health history, potential physical meet twice per week and engage in physical limitations, and personal goals. The proactivity under the care gram is individualTHE LIVESTRONG of specially trained ized for each particiLIVESTRONG at PROGRAM OFFERS THE pant – it is the best the YMCA coaches. of both worlds – the BEST OF BOTH WORLDS camaraderie of a small Numerous studies have illustrated the positive – THE CAMARADERIE OF group and the personal effect of exercise on attention of an indirecovery from cancer A SMALL GROUP AND THE vidualized daily plan. treatment. Physical PERSONAL ATTENTION The primary goals of activity not only helps the program are to OF AN INDIVIDUALIZED build muscle mass and cancer survivors regain strength and stamina, strength, increase flexDAILY PLAN. it elevates one’s mood ibility and endurance, to help combat stress and depression. The and improve functional ability. Additional LIVESTRONG at the YMCA program is goals include reducing the severity of evidence-based and is guided by an expert side effects, preventing unwanted weight panel of oncologists and exercise physi- changes, and improving energy levels. LEXINGTON
Along with cardiovascular exercise and strength training, participants engage in other activities such as spinning, water exercise, TRX, yoga, and Pilates. Perhaps the greatest benefit and goal of the LIVESTRONG program is to provide a supportive social network. Participants work with specially trained staff with distinct understanding and skills needed to assist cancer survivors in their pursuit of health and well-being; and the program’s participants themselves become a unique, caring reinforcement along the way. LIVESTRONG at the YMCA classes form tight bonds, and the environment is incredibly supportive and friendly. In the words of LaDonna, cancer survivor and former LIVESTRONG at the YMCA participant, “It’s not what you’ve been, it’s what you can become.” The Y is pleased to offer LIVESTRONG at the YMCA and to bring our strength, commitment, and passion to this work. Since the program’s inception in 2011, over 200 cancer survivors have benefited from the program. To learn more about this wonderful, free service to the community, contact Dave Peterson at 859-367-7374. Live happy, live well, and LIVESTRONG at the YMCA of Central Kentucky. Dave Peterson is the director of Community Health for the YMCA of Central Kentucky ◆
Partnering with physicians to prevent breast cancer. We welcome your referrals. For more information, call
812-945-4000.
Breast Health Happens Here. The Floyd Memorial Cancer Center of Indiana High Risk Breast Cancer Clinic offers: • Review of medical and family history • Genetic testing and counseling • Genetic risk evaluation • Individualized strategies to manage risks
FloydMemorial.com/Cancer ISSUE#89 25
COMPLEMENTARY CARE
Hosparus Can Help
Hosparus chief medical officer shares thoughts about providing hospice care and encourages physicians to refer earlier BY STEPHANIE SMITH With some 15 years of experience caring for patients with life-limiting illnesses, Jim Gaffney, MD, has gained valuable insights into end-of-life issues and the benefits of choosing hospice care sooner. Gaffney, chief medical officer at Hosparus, says, “It’s rewarding to make the end of life a peaceful transition. Caring for terminally ill patients can be challenging for all who are involved because of complex medical issues and family dynamics. The Hosparus team works closely with the attending physician to achieve the common goal of patient comfort and helps the patient and family find comfort in what can be a chaotic and stressful situation.” While health care professionals may acknowledge that hospice care is for the last several months of life, many wait until the last few days to refer. Research conducted at Mt. Sinai shows hospice patients have lower Medicare costs, reduced use of hospital services, and that hospice can improve care quality (Health Affairs 2013). Gaffney adds, “I want doctors to know that the sooner they refer patients to us, the more we can help. In addition to the expert medical care, patients who are with us longer benefit from more of the psychosocial aspects of care provided by our social workers and chaplains. The entire family receives much needed support as well.” Hospice care is for patients with any
Hosparus accepts Medicare, Medicaid, and many forms of private insurance. Thanks to its generous donors, Hosparus cares for patients and their families regardless of their ability to pay. Gaffney notes, “What many don’t know is that as part of the Hospice Medicare Benefit, medications related to the terminal diagnosis are covered and most often delivered to the home. This also is true for durable medical equipment. This is a huge relief to the families we serve.” He says, “In addition, Hosparus offers up to 13 months of bereavement care at no charge to Hosparus families after the death.” Jim Gaffney, MD For more than 35 years, Hosparus, a fully accredited life-limiting illness with a six month life non-profit hospice organization, has provided expectancy if the disease follows its normal care, comfort, and counseling for people facing course. Hosparus cares for patients with a life-limiting illnesses in Kentucky and Southern variety of illnesses including chronic heart Indiana. Hosparus cares for more than 6,000 failure, Alzheimer’s disease, Lou Gehrig’s patients and their families each year. disease, chronic obstructive pulmonary The organization’s 450 health care prodisease, dementia, liver disease, renal dis- fessionals and 800+ volunteers provide: ease, and cancer – anything that limits the • control of symptoms such as pain, naupatient’s life. sea, vomiting, shortness of breath, and restlessness • medication management HOSPARUS NAMES JIM GAFFNEY AS ITS CHIEF MEDICAL OFFICER • personal care such as bathing, skin care, and light housekeeping Hosparus recently named Jim Gaffney, MD, senior vice president/chief medical • counseling and spiritual care officer. Gaffney joined Hosparus as full-time medical director of the organization’s • bereavement counseling. Barren River and Central Kentucky locations four years ago. In his new role, he provides medical oversight and physician supervision throughout Hosparus’ All services are delivered wherever a 33-county footprint. patient calls home: a family residence, a Gaffney is a graduate of the Schulich School of Medicine and Dentistry at the nursing home, an assisted living facility, University of Western Ontario. He is board certified in hospice and palliative an inpatient unit, or a hospital. For more medicine and family medicine. ◆ information, visit www.hosparus.org or call 800-264-0521. ◆
LOUISVILLE
26 MD-UPDATE
PHOTO COURTESY OF HOSPARUS
NEWS EVENTS ARTS
Gibson joins KentuckyOne Health Medical Group
LOUISVILLE Wayne Gibson,
MD, has joined the KentuckyOne Health Medical Group. The cardiologist is practicing at KentuckyOne Health Cardiology Associates (formerly the Heart Clinic of Louisville, PSC), located at 601 North Shore Drive, Suite 102, in Jeffersonville, Indiana. The physician is board-certified in cardiology and is a fellow of the American College of Physicians and of the American College of Cardiology. He is also a member of the American Society of Nuclear Cardiology. Gibson completed his bachelor of medicine and surgery degree at the University of the West Indies, Jamaica, and completed a fellowship in cardiology at Columbia Presbyterian Medical Center and Harlem Hospital in New York City. His advanced studies include a fellowship in nuclear cardiology at the Mayo Clinic Graduate School of Medicine in Rochester, Minnesota. Gibson founded the Heart Clinic of Louisville, PSC in 1997, a solo-cardiology practice, prior to joining KentuckyOne Health Medical Group.
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gastroenterology at the University of South Carolina and a fellowship in hepatology and liver transplantation at the University of Miami School of Medicine. Kapur is a member of the American Medical Association, American College of Gastroenterology, American Society of Gastrointestinal Endoscopy, and the American Society of Study of Liver Diseases.
Oropilla joins KentuckyOne Health Neurology Associates
Joseph Oropilla, MD, has joined KentuckyOne Health Neurology Associates. His main office will be at Medical Center Jewish South, which is located at 1905 West Hebron Lane, Suite 208, in Shepherdsville. The neurologist received his bachelor of arts degree in biology from the University of Louisville; completed medical school at the University of the East in the Philippines; completed a residency in neurology at the University of Louisville; and earned a fellowship in electrophysiology at U of L. He is board-certified in neurology. After working for a neurologic group practice in Elizabethtown, Oropilla began 16 years of solo practice there, while starting Kapur satellite clinics in Greensburg, Bardstown, Affiliated with Columbia, and Campbellsville. KentuckyOne During his career, the physician has Health diagnosed and treated patients with headLOUISVILLE Ashok Kapur, aches, numbness, tingling and weakness, MD, with Associates memory loss, dizziness, syncope, unsteadiin Gastroenterology, ness, tremor, sleep disorders, trigeminal neuis now affiliated ralgia, Parkinson’s Disease, epilepsy, stroke, with KentuckyOne multiple sclerosis, meningitis, encephalitis, Health. Kapur is accepting patients at and amyotrophic lateral sclerosis, or ALS. the medical practice, located at 4402 He has performed various diagnostic proceChurchman Avenue, Suite 201 in Louisville. dures, including EMGs, NCVs and EEGs. Kapur has practiced at Sts. Mary & Oropilla has also seen a significant numElizabeth Hospital for more than 13 years. ber of Fort Knox soldiers and their family Prior to that, he practiced in Hardinsburg, members. In addition to other disorders, Kentucky. He has more than three decades he has dealt with traumatic brain injuries, of experience. He completed a fellowship in seizures, and disability issues. SHEPHERDSVILLE
Baptist Neuroscience Associates Welcomes Abou-Chebl
Baptist Neuroscience Associates recently welcomed interventional neurologist Alex Abou-Chebl, MD, to their team. Abou-Chebl is board certified in neurology and vascular neurology. He received his medical degree from Case Western Reserve University School of Medicine, Cleveland in 1995 and completed his residency in neurology at the New England Medical Center in Boston in 1999. Abou-Chebl received his fellowship training at the Cleveland Clinic in stroke, interventional neurology, and neurological critical care. He also completed a sub-fellowship in interventional neuroradiology at the Lahey Clinic in Burlington, MA in 2002. His clinical interests include the treatment of stroke, TIA, carotid stenosis, aneurysm, and clinical stroke research. Baptist Neuroscience Associates is located at 3900 Kresge Way, Suite 56, in Louisville. He joins Tracy Ander, DO, Hal Corwin, MD, Tracy Eicher, MD, MSCS, James E. McKiernan, Jr., MD, Gregory Pittman, MD, David Salvatore, DO, and Madhuri Vallabhuni, MD. LOUISVILLE
Cole Joins Baptist Health Center for Advanced Neurosurgery L O U I S V I L L E
Neurosurgeon John S. Cole, IV, MD, recently joined the Baptist Health Center for Advanced Neurosurgery. He joins Johnathan Hodes, MD, and nurse practitioners Kelly Kiesler, MSN, APRN, and Lara Bird, APRN. Cole is a 2000 graduate of the University of Kentucky College of Medicine. He completed his surgery internship at Tripler Army Medical Center in Honolulu, Hawaii. He is fellowship trained in neurosurgery and spine, completing both at the University of Kentucky in Lexington. ISSUE#89 27
NEWS The Baptist Health Center for Advanced Neurosurgery is located at 3900 Kresge Way, Suite 41 in Louisville, Ky.
Myers named Chief Health Integration Officer for Baptist Health
The Baptist Health Family’s first chief health integration officer has been named, and it is a familiar face. Isaac J. Myers II, MD, has assumed the role of CHIO. Myers joined Baptist Health in February 2014 as president of the new Baptist Health Medical Group, a position he will continue to hold even as he takes on the CHIO role. Since coming aboard, Myers has been leading a critical project – consolidating all of its employed physician entities across the system – which is expected to be completed by January. The CHIO will lead Baptist Health’s
28 MD-UPDATE
efforts to develop and implement population health strategies. In addition, he will oversee Bluegrass Family Health, Employer Solutions and Managed Care/Revenue Cycle. The new position was created in part to help tackle the new concept of population health, moving the system toward a culture of “well care,” rather than “sick care.” Myers previously served as president of Saint Francis Medical Group (Central Indiana Region) with Franciscan Saint Francis Health in Indianapolis, where he led the multispecialty medical group through rapid and constant health care reform, focusing on strategy development, leadership, and the development and integration of acute and ambulatory services and partnerships. Prior to Saint Francis Myers served for over 10 years collectively as senior executive for Indianabased managed care organizations Advantage Health Solutions and Prudential Health Care. Myers started his career in health care administration in 1994 and left private practice as a family practitioner in 1996 to begin a nearly 20-year career in administrative roles that provided opportunities to create effi-
ciencies while consistently improving quality.
Ambati Honored with NIH Director’s Pioneer Award
Dr. Jayakrishna Ambati, professor & vice chair of the Department of Ophthalmology & Visual Sciences at the University of Kentucky, was chosen to receive the prestigious National Institutes of Health (NIH) Director’s Pioneer Award, one of only 10 recipients in 2014. He is the first ophthalmologist to win this award since its inception in 2004. The Pioneer Award – the first ever to an institution in Kentucky – totaling $3.76 million over five years, is given to exceptionally creative and visionary scientists who propose highly innovative approaches to major challenges in biomedical research that could yield potentially high payoffs for human health. Ambati, who holds the Dr. E. Vernon & Eloise C. Smith Endowed Chair in Macular Degeneration Research, received the Pioneer Award to support his study of a newly discovered type of DNA that could have a profound impact on biology and medicine. Ambati, who came to the University of Kentucky in 2001, also sees patients with retinal disorders, with a particular emphasis on age-related macular degeneration (AMD), a leading cause of blindness worldwide. His laboratory’s groundbreaking research on the mechanisms that control cell death and vascular growth have led to fundamental insights into the factors that lead to development of AMD. His group has recently developed a new therapeutic to treat the dry form of AMD known as geographic atrophy, which they are planning to test in clinical trials for this currently untreatable condition that affects millions worldwide. Ambati is a Fellow of the American Association for the Advancement of Science, an elected member of the Association of American Physicians, American Society for Clinical Investigation, Macula Society, and Club Jules Gonin, and American Society of Retinal Specialists. He also serves on the Editorial Boards of Investigative Ophthalmology & Visual Science, Ophthalmology, and Translational Vision Science & Technology. His work has been previously recognized with awards from the American Geriatrics Society, Association for Research in Vision & Ophthalmology, LEXINGTON
NEWS Burroughs Wellcome Fund, Canadian National Institute for the Blind, Doris Duke Charitable Foundation, Ellison Medical Foundation, Foundation Fighting Blindness, Harrington Discovery Institute, and Research to Prevent Blindness.
Cook joins KentuckyOne Health Medical Group as COO of Louisville Market
David Cook, CPA, MBA, CMPE, has joined KentuckyOne Health Medical Group as the COO of the Louisville market. The health care executive has more than 25 years of experience in leading physician organizations for hospital systems. He has successfully led start-ups and turnarounds, often during periods of rapid growth and intense competition. In his new role, he will be responsible for exercising administrative responsibilLOUISVILLE
ity, accountability, and authority for the day-to-day management and operation of the KentuckyOne Health Medical Group’s Louisville market. He will ensure that the medical group has the proper operational controls; administrative and reporting procedures; people; and systems in place to effectively grow the organization, and to ensure financial strength and operating efficiency. In addition, he will develop and maintain the infrastructure of administrative operating systems among clinics so that the KentuckyOne Health Medical Group delivers high quality, cost-effective health care. Most recently Cook was the founding lead executive for ProHealth Solutions, a clinically integrated network of 460 physicians and two hospitals located in Waukesha, Wisconsin. Prior to that he was chief administrative officer for Waukesha Elmbrook Health Care, S.C., a clinically integrated IPA. He has also led physician practices for Carle Foundation Hospital in Urbana, Illinois, and has served as president of CARITAS Physician Group in Louisville. ◆
JAMES SHAMBHU WORKING HARD TO REMAIN STILL
New works on plaster & paper Nov 21 - Dec 17, 2014
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116 old lafayette avenue Opening Friday Nov. 21 LexArts Gallery Hop
THE BUSINESS
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ONCOFERTILITY AND PEDIATR IC ONCOLOGY
THE BUSINESS MAGAZINE OF KENTUCKY PHYSICIANS
WOMEN’S HEALTH PEDIATRICS
UK pediatric specia lists Dr. Leslie Appia h and Dr. Lars Wagn er honor the resilience of young cancer patients Pictured:
AND HEALTHCARE PROFESSIONALS Volume 5, Number
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Leslie Appiah, Md
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ISSUE#89 29
EVENTS
GLMS FOUNDATION SCHOLARSHIP GOLF TOURNAMENT
The fourth annual GLMS Foundation Scholarship Golf Tournament was played under sparkling blue skies and breezy conditions at the Hurstbourne Country Club on September 22, 2014. Proceeds from the event go to the scholarship fund for Kentucky medical school students. LOUISVILLE
The Passport Health Plan team of John Mason, Lisa Butcher, Mark Carter, CEO, and Verkat Sharna played a round of golf to support the GLMS Foundation Scholarship Fund. (L-R)
Hall, Butch Welseher, Hobie Pence, MD (ret.), and Jesse Jenkins, the Kentuckiana Allergy & Asthma team, enjoyed the fresh fall air and each other during their round of golf for the GLMS Foundation.
(L-R) The
team of David Watkins, MD (ret.), Russell Williams, MD, Ron Daniel, and Danny Watkins put their experience into play with a good putting game.
A foursome of physicians took to the course to raise scholarship money for medical school students. (l-r) Tommy Thompson, MD, Neil Patil, MD, Mark Ihnen, MD, and Robert Caudill, MD.
(L-R) The
Family Allergy & Asthma team of Michael Tanoury, Kay Tyler, Doug Lotz, MD, and Roger Perkins put some breathing room between themselves and the competition with timely birdie putts.
The team from Mountjoy Chilton Medley counted and re-counted their strokes very carefully. (L-R) Steve Schulz, Bonnie Cirsi, Cris Miller, and Chris Melton.
(L-R) Steve
(L-R) The
U of L team of LaBradford Smith, Jane Ramsey, Claire Alagia, and Scooter McCray looked for long drives and a few birdies during their round.
30 MD-UPDATE
(L-R) A
sunny day and a good cause brought out the smiles for the foursome of Charles Bisig, MD, Jackie McClean, Christian Furman, MD, and Dean Furman.
Dr. R. John Ellis, Ellis & Badenhausen, (center) shared a fun moment with members of tournament sponsor Stockyard Bank & Trust, (L-R) Suzanne Barnes and Tracie Frist.
(L-R) Playing
(L-R)
for Norton Suburban were Tommy and Pamela Gregory with Dawn and Ron Stambaugh.
Paul Kalbfleish, Linda Gleis, MD, chair GLMS Foundation Scholarship Golf Tournament, son Eric Gleis, and Jimmy Ford were happy to be playing golf and raising money for the cause.
EVENTS
DOCTORS’ BALL HONORS PHYSICIANS
The annual Doctors’ Ball, presented by KentuckyOne Health and the Jewish Hospital and St. Mary’s Foundation was Saturday, October 18, 2014 at the Marriott Louisville Downtown. Over 750 finely attired and festive supporters attended to give to the Foundation and to honor the evening’s special guests. Honored were: Ardis Hoven, MD, Ephraim McDowell Physician of the Year; Roberto Bolli, MD, Excellence in Research; Morton Kasdan, MD, Excellence in Education; and Ron and Marie Abrams, Community Leaders of the Year. Proceeds of The Doctors’ Ball benefit the Jewish Hospital and St. Mary’s Foundation, which contributes funds to patient care facilities and services, provider and caregiver education, advanced clinical research, and improved patient care. LOUISVILLE
(L-R) Dr.
Jeffrey and Jennifer Tuvlin strike a handsome and smiling pose at the Doctors’ Ball. Darryl Kaelin, MD, and wife Brenna Kaelin, RN, chose a matching accent color for the Doctors’ Ball.
(L-R) No
wonder he’s smiling! Deborah A. Ballard, MD, Alexa and Damian “Pat” Alagia, MD, with Toni Ganzel, MD.
Ardis D. Hoven, MD, honored as the Ephraim McDowell Physician of the Year, with Shawn Jones, MD, KMA pastpresident, and wife Evelyn Jones, MD. (L-R)
Honoree Roberto Bolli, recipient of the Excellence in Research award, with sons Roberto Jr. and Robi, and wife Amy.
LEXINGTON CLINIC FOUNDATION GOLF TOURNAMENT CELEBRATES 10 YEARS
Lexington Clinic Foundation celebrated the 10th Anniversary Golf Tournament, September 8, 2014. Chaired by Mike Marnhout, CEO Bluegrass Oxygen, and presented by Lexington Clinic, the tournament had more than 140 registered players. The tournament was held at the University of Kentucky Golf Club. This annual tournament fills both courses and gives players the opportunity to win prizes ranging The winning team at from crystal trophies to a two-year lease on a Cadillac. Lexington Clinic Foundation Proceeds from the annual tournament support Lexington Golf Tournament was Clinic Foundation’s activities in three areas: scholarships Dan Howard, Bruce Broudy, MD, for students studying the allied health sciences, health Wayne Colin, MD, and innovation, and community grant programs. Mike Marnhout. LEXINGTON
PHOTO COURTESY OF STEPHANIE NORTHERN
ISSUE#89 31
EVENTS
Twenty-three past presidents of the Lexington Medical Society gathered for the annual meeting.
Lexington Medical Society Past President and KMA Trustee Meeting has Big Turnout
On October 14, 2014, 23 past presidents of the Lexington Medical Society (LMS) gathered for the annual past president’s meeting ,which coincided with the KMA 10th District Trustee meeting. The Trevey Award for Community Service was given to Dr. Thomas Slaybaugh, Sr., and Dr. John Collins. The Carolyn Kurz Lay Person Award was given to Mary Ellen Amato, RN. LMS Commendations were given to Dr. John Riley for 25 years of service to the Fayette County Board of Health and to Dr. Thomas Young, Kathleen Eastland, and Dr. William Underwood for their work at Baby Health Service, which recently celebrated 100 years of service.
COME PLAY
LEXINGTON
32 MD-UPDATE
(L-R) Kaveh (L-R) Danesh
R. Sajadi, MD, Marian. H. Bensema, MD, John W. Collins, MD, and Larry L. Cunningham, Jr., MD, gathered at the LMS past presidents meeting.
(L-R) Dr.
(L-R) Dr.
Mazloomdoost, MD, and David J. Bensema, MD, KMA president at the LMS meeting.
John Collins was honored for his leadership for 25 years of the LMS Foundation’s Golf Tournament, and Dr. Thomas Slaybaugh, Sr., was honored for his leadership of Surgery on Sunday.
Preston Nunnelley, chief medical officer Baptist Health Lexington and 1984 LMS president, with KMA Executive VP Patrick Padgett.
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