Banner MD Anderson Rounds - Fall 2013

FALL 2013

A PUBLICATION FOR COMMUNITY PHYSICIANS

Changes in prostate testing Banner MD Anderson Cancer Center oncologists developing ways to help those with prostate cancer live longer, even as doctors pass on recommending screening for the disease earlier

BY JIMMY MAGAHERN

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arely does it pay to procrastinate — especially when it comes to taking care of your health. But for men over 50 who are still putting off getting that dreaded prostate cancer screening done, relax: doing nothing just might be the best choice after all.

That, in a nutshell, is the finding published last year by the U.S. Preventive Services Task Force, which firmly came out against routine prostate-specific antigen (PSA) screening for prostate cancer. The hotly-debated reversal on the decades-old practice of routinely recommending PSA tests to every male over 50 concluded that, for the majority of those tested, the tests might actually do more harm than good, leading to unnecessary surgery, radiation and hormone therapy that creates more harmful side effects than benefits.

“If you’ve been putting it off, you’re probably one of the smart people,” says Farshid Dayyani, MD, Ph.D., medical oncologist at Banner MD Anderson Cancer Center in Gilbert.

TASK FORCE FINDINGS For every thousand men screened, the task force found, only one manages to beat the inevitable, and avoid cancer.

Meanwhile, up to one-third will end up

with urinary incontinence, bowel problems or impotence from the treatments elected to fight cancers that, odd as it sounds, the patient often could have lived with anyway.

“The PSA is a good test of the prostate gland,” Dayyani explains. “But it’s a bad test for cancer, in that it’s not specific to cancer. A prostate infection will increase your PSA level; a prostate biopsy will increase your PSA level. So you have a lot of false-positives. People who get the biopsy but then turn out not to have cancer.”

Even when the screening is right, and it correctly detects the development of prostate cancer, Dayyani says, what it’s catching is more often than not a slow-moving villain that seldom ends up being the body’s killer. “People end up carrying out a diagnosis of, quote-unquote, ‘cancer’ on conditions that nine out of 10 of them wouldn’t have died from anyway, even if no one had diagnosed it.”

PROLONGING LIFE Specialists have yet to come up with a better test for detecting prostate cancer early, and PSA’s, according to the April

INSIDE

2 CME Event

3 Treatments and Procedures 4 Blood Cancer Program

5 The Undiagnosed Breast Clinic

Farshid Dayyani, MD, Ph.D., medical oncologist at Banner MD Anderson Cancer Center in Gilbert

6 What’s happening at Banner MD Anderson 7 Interventional Radiology with Dr. Andrew Price 8 Banner MD Anderson physicians

2013 recommendations of the American Urological Association, can still benefit men between the ages of 55 to 69, African-American men and those with a family history of prostate cancer.

Dayyani stresses the importance of ongoing research to identify with novel screening methods those patients who are actually at risk of dying from their prostate cancer, as for them, early detection and treatment is the only recourse.

“Ultimately, there should be a thorough discussion between men and their health care provider regarding risks and benefits,” he says, “as well as the patient’s values, prior to deciding for or against screening.”

But Dayyani says the more exciting work in his field involves helping those who do develop prostate cancer live longer, and better.

Physical castration (orchiectomy, for those who cringe at the very word), is

seldom prescribed anymore, at least in the U.S., to stem the testosterone that cancer cells like to grow in. “For psychological reasons, in this country, we do chemical castration,” says the Munichtrained specialist, who transferred to the East Valley in 2011 following a fellowship at The University of Texas MD Anderson Cancer Center in Houston.

“Which means we’re giving hormone shots to shut down the testosterone production in the testicles.”

NEW DRUGS PROVE EFFECTIVE Even that procedure, temporary in that the cancer cells eventually find their own pathways without the testosterone, is being replaced by promising new drugs.

“This is where the field has been moving fastest,” says Dayyani. Novel biologic drugs like Taxotere and Jevtana have proven effective, he notes. But the new hormonal drugs, like Zytiga and Xtandi, are “much better tolerated than

the chemotherapy drugs, because they don’t have the side effects.” Dayyani also remains partial to Provenge, the first cancer vaccine to receive FDA approval.

“In trials, the tumor did not shrink, but the disease course slowed down, and patients in the Provenge group lived 25 months longer.”

For Dayyani, stretching the prostate cancer patient’s lifespan on what he calls “the right end of the spectrum” is more important than the patient discovering the cancer’s onset on the left end of the age chart.

“The screening conundrum is at the very, very early stage of the disease, among patients who don’t even have any symptoms,” he says.

“But the exciting, novel treatments are on the other side of the spectrum, with patients who no longer respond to primary treatments. This is where we’ve made the biggest advances in the past decade.”

Banner MD Anderson to host Innovations in Oncology symposium at Hyatt Regency

BY GREMLYN BRADLEY-WADDELL

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espected authorities from the medical and scientific communities will share the latest advancements in cancer treatment and research at the second annual “Innovations in Oncology” symposium this November.

Sponsored by Banner MD Anderson Cancer Center in Gilbert, the two-day event will feature local and national speakers including Merrill Kies, MD, professor of Medicine in the Department of Thoracic/Head and Neck Medical Oncology at The University of Texas MD Anderson Cancer Center, and Raymond DuBois,

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MD, Ph.D., executive director of the Biodesign Institute at Arizona State University. Kies’ research interests include combined modality treatment of head/neck cancer and non-small cell lung cancer, new drug development and rehabilitation in head and neck cancer. DuBois, a former provost and executive vice president and professor of cancer medicine and cancer biology at The University of Texas MD Anderson Cancer Center, is recognized as an expert in the molecular and genetic basis for colorectal cancer.

“These types of outreach opportunities are critically important in terms of patient care and scientific advance-

ment,” says Banner MD Anderson research director Lee Seabrooke.

The symposium, which will be comprised of lectures and Q&A-style sessions, also will give oncologists and specialists who treat cancer patients from around the state a chance to learn about emerging research programs at Banner MD Anderson, specifically the transplantation program and head/ neck oncology program.

The event runs Nov. 15-16 at the Hyatt Regency Scottsdale Resort and Spa at Gainey Ranch in Scottsdale. For more information, contact Seabrooke at lee.seabrooke@bannerhealth com.

Transplanting hope in cancer patients

New transplants, treatment options coming to Banner MD Anderson Cancer Center

BY KERRY HAMILTON

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anner MD Anderson Cancer Center in Gilbert continues to usher in a new era of cancer care in Arizona, reflected by a series of four successful stem cell transplants performed on patients with multiple myeloma from May to July 2013. Two additional patients with relapsed non-Hodgkin lymphoma are currently being prepared for autologous stem cell transplantation.

For patients suffering from hematologic malignancies and other blood and bone marrow disorders, often the only treatment option with curative potential is stem cell transplantation.

Adding this critical service further reinforces Banner MD Anderson’s position as a renowned destination for leadingedge cancer care in the Southwest.

TRANSPLANT OPTIONS EXPANDING When high dose chemotherapy or radiation is deemed the most effective treatment to eliminate cancer cells, the process often destroys healthy marrow and an autologous stem cell transplant replenishes damaged cells.

Allogeneic stem cell transplants from related, unrelated and haploidentical donors have a powerful effect in directly treating certain diseases, like acute leukemia, myelodysplastic syndrome and aplastic anemia, by using donated stem cells to fight the offending cells and restore those compromised by cancer or bone marrow failure.

Currently, Banner MD Anderson’s highly specialized team performs autologous stem cell transplants and will expand to allogeneic transplants

this fall, enabling physicians to leverage multiple donor stem cell options, including those from patients, family members, umbilical cord blood units, and unrelated donors who are a near match.

“Our stem cell transplant options incorporate the latest medical advances and show tremendous promise for treating all manner of hematologic disease,” says Dr. Görgün Akpek, MD, MHS, FACP, director of the center’s Stem Cell Transplantation and Cellular Therapy Program.

TREATMENT PROTOCOLS AND PERSONALIZED CARE The Stem Cell Transplantation and Cellular Therapy Program is equipped to treat acute and chronic leukemia; Hodgkin and non-Hodgkin lymphoma; multiple myeloma and AL amyloidosis; myelodysplastic syndrome; myelofibrosis; aplastic anemia; and other hematologic cancers and bone marrow failure disorders.

“Stem cell transplantation is a highly complex yet effective course of treatment in the right situations,” says Dr. Akpek. “We screen potential candidates using protocols fully adopted from The University of Texas MD Anderson Cancer Center to determine if transplantation is indicated and engage a weekly multidisciplinary tumor board to identify the optimal treatment approach for each patient. We are also introducing new clinical trials to further improve the safety of transplant modality and the curability of underlying diseases and conditions.”

BannerMDAnderson.com

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Committed to growing knowledge and research

Banner MD Anderson Cancer Center launches lymphoma/myeloma initiative

BY MARY VANDEVEIRE

“Extrapolating data from other malignancies, decoding the genetic blueprint he University of Texas MD of multiple myeloma, seems to be the Anderson Cancer Center is way of moving forward in oncology.” devoted to developing growAdvances in next-generation ing expertise in diverse specific types DNA sequencing technologies allow of malignancies. In support of this for faster and less costly testing of tiscommitment, Banner MD Anderson sue specimens. Dr. Muñoz notes that Cancer Center in Gilbert launched a recent studies have shown that diflymphoma/myeloma initiative, offerferent genes involved in the nuclear ing diagnostic testing and imaging, as factor (NF)-kappaB pathway seem well as treatments such as chemotherto be involved in the development apy, immunomodulators, radiation of multiple myeloma. Furthermore, therapy and stem cell transplantation. a minority of multiple myeloma patients (4 percent) have been found TARGETED THERAPY to harbor a BRAF gene mutation that Main interests of the Banner MD is common in melanoma and colon Anderson initiative are to decipher cancer, perhaps hinting at the posthe molecular heterogeneity of sibility of another molecular target multiple myeloma, in this condition. and sub-classify “This is a very specific plasma cell exciting time in dyscrasias amenable oncology for the to a particular targeted treatment of multherapy. Javier Muñoz, tiple myeloma,” MD, FACP, is among Dr. Muñoz says. the investigators “Various pipeline leading Banner MD drugs are currently Anderson’s lymphoin clinical trial testma/myeloma initiaing (pomalidomide, tive. Dr. Muñoz is first daratumumab), — Javier Muñoz, MD, FACP author of “Molecular soon to be added profiling and the to the ever-growing reclassification of cancer: divide and roster of FDA-approved drugs for this conquer,” a chapter in the American condition (lenalidomide, bortezomib, Society of Clinical Oncology Educacarfilzomib). As an example, daratutional Book 2013. mumab is a monoclonal antibody “Making personalized medicine directed against the CD38 marker, a reality will be the true challenge in which is highly expressed on the surface of multiple myeloma cells.” years to come,” Dr. Muñoz says.

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Making personalized medicine a reality will be the true challenge in years to come.

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Javier Muñoz, MD, FACP

MULTIDISCIPLINARY PROGRAM The Banner MD Anderson Blood Cancer Program takes a multidisciplinary approach at its weekly Hematology Tumor Board meetings, where difficult cases are discussed by experts in specialties including radiology, pathology, radiation-oncology and stem cell transplantation.

The Banner MD Anderson Stem Cell Transplantation and Cellular Therapy Program is actively receiving referrals of multiple myeloma patients, Dr. Muñoz says, noting that autologous transplantation is currently standard of care consolidation after initial response to chemotherapy.

“The advent of the Stem Cell Transplantation Program at Banner MD Anderson heralds the opportunity to distinguish ourselves as a center of excellence when treating patients with plasma cell dyscrasias and hematologic malignancies in general,” Dr. Muñoz says.

Helping patients

get speedy answers

Banner MD Anderson Cancer Center’s Undiagnosed Breast Clinic provides services under one roof

BY DEBRA GELBART

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hen a patient experiences breast pain, discovers a breast lump or is told her mammogram is questionable, the Undiagnosed Breast Clinic at Banner MD Anderson Cancer Center in Gilbert can help ease her worries and help her referring physician. The Clinic, which is open to men, too, opened in April of last year and provides clinical exams, diagnostic imaging, procedures, treatment if necessary and follow-up— all under one roof and with lab and pathology results available to the patient within 48 hours.

Most patients who come to the Clinic will meet with Shefali Birdi, MD, an internal medicine physician who came to Banner MD Anderson last September from the Cleveland Clinic.

Already, she has seen close to 150 patients (including a couple of male patients) from all over the Valley and as far away as northern California.

Q: How does the Undiagnosed Breast Clinic support referring physicians?

Dr. Birdi: Our clinic serves as a great entry point for patients into our health system. Many of our patients are selfreferred; others are sent to us from community physicians. Once they are seen in our clinic, they are referred to other specialists in our system, if appropriate.

We are also always here as a resource for physicians who may have patients with undiagnosed breast concerns.

Q: How does a physician refer a patient to the Clinic and under what circumstances would that referral occur?

Dr. Birdi: If a physician has patients with concerns regarding abnormal breast imaging, findings on exam or breast symptoms, we would be happy to see them in our Clinic. The referring physician should request an Internal Medicine Consult and specify “Undiagnosed Breast Clinic” in comments/reason for visit.

issues that fall under the physician’s scope of practice.

Q: What kind of communication does the Clinic maintain with a referring physician?

Dr. Birdi: A copy of our note is faxed to the referring physician and we are also always available for conversation regarding the patient’s plan of care.

Q: What are the advantages for physicians to establish and maintain a relationship with the Clinic?

Q: Does a referring physician

Dr. Birdi: Physicians are able to have

continue with the patient’s care during her (or his) diagnosis and treatment?

a direct resource for their patients who present with any breast concerns. We provide timely evaluation and diagnosis and we maintain communication with our referring providers.

Dr. Birdi: The referring physician should continue to be involved with the patient’s care by addressing any concerns that the doctor was primarily seeing the patient for, especially if the patient is still having

To make a referral to the Undiagnosed Breast Clinic, call 480-256-6444 and ask for the Patient Access Team.

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What’s happening at

Banner MD Anderson Cancer Center

BY DR. EDGARDO RIVERA, MEDICAL DIRECTOR

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wo years ago, when we opened Banner MD Anderson Cancer Center in Gilbert, we were welcomed by the medical community and embraced by patients who experienced the expert level of care we provide.

Every member of the Banner MD Anderson team has contributed to that success, and I thank them for your efforts. I’m personally proud that over the past two years, we’ve dedicated resources to developing and growing our various programs, and I’m delighted to share that our Breast Program now has all the components in place to be recognized as a comprehensive breast program.

Thanks to the work of Dr. Mary Cianfrocca and her tremendous team, women in the Valley have access to screening, treatment, support and recovery services all under one roof at Banner MD Anderson.

Part of the reason we’re able to provide such expert care is that we have physicians who focus exclusively on breast cancer. We have three dedicated breast cancer medical oncologists, and our second breast surgeon, Dr. Julie A. Billar, will start this month.

The breast center also boasts radiologists focused solely on breast imaging, and our radiation oncologists are specialists in breast cancer care.

Plastic and reconstructive surgeons, a palliative care physician, nurse navigators, oncology certified nurses, social

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workers, genetic counselors, dietitians and an exercise physiologist round out this dynamic team of caring professionals.

For more complex cases, a weekly multidisciplinary breast cancer tumor board brings many of our breast cancer experts together to discuss treatment options. This is just one manifestation of what a multidisciplinary breast program can offer this community.

Another is our Undiagnosed Breast Clinic. As you know, early detection is essential in treating cancer, and you may have seen our recent advertising campaign for the clinic. With a promise that “we turn your panic attack into a plan of attack,” the Undiagnosed Breast Clinic is an exciting component of the program.

A woman’s primary care physician or OB/GYN may refer her to the clinic

if she has an abnormal mammogram or a breast lump. For the majority of patients, we can provide a diagnosis by the next day. In most cases, it’s not cancer, but the peace of mind for patients is invaluable. And in those situations where it is cancer, we offer the expertise and compassionate care of our multidisciplinary Breast Cancer Program to help women fight the cancer.

If you have questions about the Undiagnosed Breast Clinic or the breast program, I’d be happy to answer them, so please feel free to reach out.

Sincerely, Dr. Edgardo Rivera Medical Director

We’re not involved in that research formally, but we see many well-educated patients who are specifically requesting radioembolization earlier in their treatment course.

— Andrew Price, MD

Sooner or later?

Radioembolization’s role in liver cancer treatment

BY BRIAN SODOMA

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r. Andrew Price has a wealth of knowledge and more than a few high-tech tools at his disposal. But the director of interventional radiology at Banner MD Anderson Cancer Center in Gilbert, says finding the best time during a treatment course to use those tools is a burning question in his field today.

Price is a radioembolization expert, a minimally-invasive, catheter-based treatment where millions of tiny spheres coated with radioactive isotopes known as yttrium-90 (Y-90) are delivered directly into the arteries of liver tumors.

This technology delivers high doses of radiation while minimizing the impact on surrounding liver tissue. The treatment has been proven safe and effective through the years, but questions are surfacing as to the best time to administer it — before, after or during chemotherapy.

Even without final results from these large clinical trials, Price is finding that more and more patients with colorectal liver metastases are asking to have Y-90 performed earlier.

IMPROVING SURVIVAL

PROMISING RESULTS

Today, Y-90 is most commonly used after several rounds of unsuccessful chemotherapy, a stage referred to as “salvage treatment.” There is a growing sense in the medical community that if Y-90, sometimes also referred to as SIRT (Selective Internal Radiation Therapy), was performed earlier in the course of treatment, patients could enjoy better outcomes like decreased tumor size and better survival rates.

Two international studies, SIRFLOX and FOXFIRE, are currently weighing whether radioembolization in combination with chemotherapy is more effective than chemotherapy alone as a first line treatment option for patients with metastatic colorectal cancer to the liver. SIRFLOX is enrolling patients from Australia, New Zealand, Europe, the Middle East and North America, while FOXFIRE is focusing on patients in the United Kingdom.

“We’re not involved in that research formally, but we see many well-educated patients who are specifically requesting radioembolization earlier in their treatment course,” he says.

“This is an outpatient procedure that is really well tolerated and proven to be really quite effective.”

In a few situations, Price has seen how some patients try Y-90 first, as they are skeptical of even trying chemotherapy at all. The encouraging results then bring a sense of hope, and these patients seem more open to expanding their treatment options to include chemotherapy.

“Often times when you are first diagnosed (with a liver metastasis), you feel pessimistic about the future. But this treatment, while not providing a cure, can prolong survival with minimal downtime, improve quality of life, and restore a sense of hope,” Price says.

BannerMDAnderson.com

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BANNER HEALTH 1441 N. 12th SREET PHOENIX, AZ 85006-2887

NONPROFIT ORG U.S. POSTAGE PAID LONG BEACH, CA PERMIT NO.1677

Banner MD Anderson Physicians

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anner MD Anderson Cancer Center in Gilbert physicians are highly specialized in their fields of expertise. Below is a listing of physicians currently on our full time staff.

Physicians continue to join Banner MD Anderson, so this list will continue to evolve.

To make a referral to a physician on our staff, please call 480-256-3433. To contact a member of medical staff, call 480-256-6444 and ask for the physician to be paged.

HEMATOLOGY & MEDICAL ONCOLOGY SECTION Tomislav Dragovich, MD, PhD, Division Chief Digestive tract cancers including colorectal, esophageal, stomach, pancreatic, hepatobiliary Gorgun Akpek, MD, MHS Director of Stem Cell Transplantation and Cellular Therapy program Santosh Rao, MD (Starts 10/1) Medical oncology Shakeela Bahadur, MD Lung, colorectal, breast cancers Mary Cianfrocca, DO Breast Cancer Program Director Farshid Dayyani, MD, PhD Genitourinary and gastrointestinal cancers Jade Homsi, MD Melanoma, sarcoma, immunotherapy H. Uwe Klueppelberg, MD, PhD Multiple myeloma and other plasma cell disorders, lymphomas, myelodysplastic syndrome, brain cancers, head and neck cancers, thoracic cancers Javier MuĂąoz, MD Lymphoma and other blood cancers

Edgardo Rivera, MD, Medical Director Breast cancer Kerry Tobias, DO Pain management, palliative medicine, physical medicine, rehabilitation Rebecca Armendariz, MD Palliative Care Matthew Ulrickson, MD Hematology, leukemia, lymphoma, stem cell transplantation Klaus Wagner, MD PhD Thoracic and Head & Neck Cancers Bryan Wong, MD Genitourinary cancers

ONCOLOGY SURGERY SECTION Judith K. Wolf, MD, Division Chief Gynecologic oncology Stephanie Byrum, MD Breast surgery Al Chen, MD General surgery Randall Craft, MD Full spectrum of both implantbased and autologous breast reconstruction, comprehensive plastic and reconstructive options for all areas of the body

Mark Gimbel, MD Melanoma, sarcoma, cancer of the stomach, small bowel, colon and rectum, thyroid, pancreas, liver, breast, and other rare cancers Karen Pitman, MD, Head and Neck Surgery Matthew Schlumbrecht, MD, MPH Gynecologic oncology; gestational trophoblastic disease; a variety of surgical techniques including radical abdominopelvic exploration and minimally invasive procedures.

Rob Schuster, MD General surgery Thomas Shellenberger, MD Recurrent thyroid cancers, cancers of the oral cavity, oropharynx, and larynx, salivary gland cancers, advanced skin cancers and melanoma of the head and neck, complications from treatment of head and neck cancer.

Diljeet Singh, MD Program Director, Gynecologic Oncology; Cancer Prevention & Integrative Medicine

RADIATION ONCOLOGY SECTION Matthew Callister, MD, Division Chief Gastrointestinal, skin, sarcomas, and head and neck cancers Dan Chamberlain, MD Thoracic and head and neck malignancies, and body radiosurgery Emily Grade, MD Breast treatment including partial breast brachytherapy, prostate brachytherapy, gynecological and thyroid cancers Anna Likhacheva, MD Breast Cancer, Gynecologic Oncology, Leukemia, Lymphoma

Susan Passalaqua, MD Director of Nuclear Medicine and Molecular Imaging oncologic imaging, nuclear medicine, radiology, PET/CT Andrew Price, MD, CAQ Interventional Radiology Interventional radiology, including percutaneous tumor ablation, chemoembolization, and radioembolization Philippe Lanauze, MD Interventional radiology

CRITICAL CARE SECTION Shiva Birdi, MD, Division Chief Jijo John, MD Deven S. Kothari, MD Dean Prater, MD Ravindra Gudavalli, MD

Terence Roberts, MD, JD Brain, lung and prostate tumors; stereotactic radiosurgery; partial breast brachytherapy

INTERNAL MEDICINE SECTION

DIAGNOSTIC IMAGING SECTION

Shefali Birdi, MD

Donald Schomer, MD, Division Chief, CAQ Neuroradiology Oncologic diseases of the brain, spine, head and neck John Chang, MD, PhD Advanced MR and CT imaging of gastrointestinal and genitourinary systems; imaging guided biopsies Vilert Loving, MD Breast imaging and intervention

Benny Tan, MD Plastic and reconstruction surgeon, breast cancer reconstruction and most forms of cancer reconstruction

Harvinder Maan, MD, CAQ Neuroradiology Director of Neuroradiology Neuroradiology and interventional spine procedures

Julie Billar, MD Surgical oncologist, breast cancer

Rizvan Mirza, MD Abdominal and pelvic magnetic resonance imaging

Nikunj Doshi, DO, Division Chief David Edwards, MD Ronald Servi, DO

PATHOLOGY SECTION Kevin McCabe, DO, Division Chief