Banner MD Anderson Rounds - March 2012

A PUBLICATION FOR COMMUNITY PHYSICIANS

MARCH 2012

Inflection point

at the leading edge of developing the

Biologic state imaging is the next step in the evolution of diagnostic imaging — and providing clinicians with better tools for personalized cancer treatment

BY JAKE POINIER

“E

very decade or so, radiology has had an inflection point that revolutionizes how we image and diagnose patients,” said Dr. Don Schomer, Diagnostic Imaging Section Chief at Banner MD Anderson Cancer Center. In the 1960s, it was catheter-based angiography, and in the 1970s, it was nuclear medicine.

The ‘80s, ‘90s and early 2000s saw the advent of CT scanning, MR and functional MR, and PET CT, respectively.

While each of these new techniques put new tools in the hands of radiologists and physicians, they also had their shortcomings. Nuclear imaging showed activity in three dimensions, but without anatomic precision. A CT gave an anatomic perspective, but didn’t add localization.

biologic state imaging, a hybrid technique that combines functional and molecular imaging to make decisions about the biologic state of an organ system or a tumor in question. Banner MD Anderson Cancer Center is

techniques, along with The University of Texas MD Anderson Cancer Center in Houston and institutions such as UCLA and Stanford. Schomer describes the resulting images as absolutely amazing, offering a 3D image with a temporal component.

“At Banner MD Anderson, we’re very passionate about cancer — that’s the reason we exist,” Schomer said. “For diagnostic imaging, our

STATE OF IMAGING “In the mid 2000s, PET really took off because of CT, because it heralded the concept of a molecular-based dimension,” Schomer said. “Now, you’re not just looking at anatomy, but how it’s functioning on a molecular level.

There are a whole host of questions that a molecular study can’t answer, but an MRI and CT can. How densely packed are the cells in a tumor? How leaky are the vessels?”

Schomer believes that the next inflection point in radiology is

Dr. Don Schomer, Diagnostic Imaging Section Chief at Banner MD Anderson Cancer Center, with Dr. Susan Passalaqua, Director of Nuclear Medicine and Molecular Imaging.

INSIDE 3 New hope for endocrine cancer patients

4 What’s happening at Banner MD Anderson 5 Nurses are heartbeat of hospital

6 ‘Flavor profiling’ aids chemo patients 7 Partial breast radiation treatment

speeds recovery

Suspicion of Cancer Program is game changer in early detection Most patients who come to Banner MD Anderson Cancer Center already have a diagnosis of cancer. But sometimes a person may have radiological or lab abnormalities, or even symptoms that raise suspicion, and they’re not sure where to go.

Banner MD Anderson’s new Suspicion of Cancer Clinic is targeted at precisely this type of early detection. “Our goal is to expedite the workup and get them to the right physician, because oncologists are very specialized,” says David Edwards, M.D., section chief of internal medicine at the Banner MD Anderson Cancer Center and a part-time clinician working in the program.

The staff includes two general internists and one pulmonologist. The process operates on a similar principle to triage in an emergency room, starting with a conversation between the patient and a nurse clinical navigator.

task is to give oncologists ways of understanding the state of a patient’s tumor before, during and after therapy. Ultimately, the vision is to help clinicians manage these tumors on a personalized basis.”

TECHNOLOGY CHANGES The new technology has become even more essential because of broader changes in cancer therapies.

“The old paradigm of the way you image cancer is that you measure it, and then you give it some poison and it shrinks,” Schomer said. “Your success is gauged by how much volume loss there’s been in the tumor.

More-personalized cancer therapies, however, are cytostatic rather than cytotoxic—they halt the process, they

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What we hope to do with the biologic state techniques is, when a patient goes onto a therapy, to tell the oncologist very quickly that the therapy is working or not, so they can maintain their current course or try something else.

— Dr. Don Schomer, Diagnostic Imaging Section Chief, Banner MD Anderson Cancer Center

don’t make it shrink or die or go away.

Or oncologists may use combinations of the two therapies.”

From an imaging point of view, however, it’s very difficult to know that a tumor treated with a cytostatic therapy is quiescent. Since these agents

“If a patient already knows he has cancer, they’ll talk about how was it diagnosed, and what type of cancer it is,” said Edwards. “If someone has a spot on her lung, but hasn’t had a workup, the navigator will direct her to the appropriate physician. We even talk to ER physicians with a patient who they believe has cancer, but don’t have an official diagnosis.”

Physicians can refer patients to the Suspicion of Cancer Clinic by calling (480) 256-3433. Patients can also self-refer by calling (480) 256-6444. are so expensive, that’s a critical piece of data—one that biologic state imaging is perfectly suited to provide.

“The holy grail of biologic state imaging is moving from PET CT to PET MRI,” Schomer said. “What we hope to do with the biologic state techniques is, when a patient goes onto a therapy, to tell the oncologist very quickly that the therapy is working or not, so they can maintain their current course or try something else.”

New center offers endocrine cancer patients new hope

Banner MD Anderson Cancer Center’s surgical team successfully treats both rare and routine cases

BY ANDREA MARKOWITZ

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ithin a few months of Banner MD Anderson Cancer Center’s (BMDACC) opening on September 26, 2011, Christine Landry, MD, and her surgical team already successfully treated a patient with a rare genetic condition called von Hippel Lindau disease.

“This patient had a history of bilateral cerebellar hemangioblastomas and was later diagnosed with bilateral pheochromocytomas,” said Dr. Landry, a surgical oncologist/endocrinologist.

The surgical team performed a corticalsparing bilateral adrenalectomy, she explained. By preserving the cortex and removing the tumors, they were able to

wean the patient off all blood pressure medications and avoid the need for long-term steroids.

TREATING THYROID CANCER The physicians at BMDACC treat thyroid cancer patients just as aggressively.

According to Dr. Landry, patients are evaluated with a thorough ultrasound of the soft tissues of the head and neck. Any suspicious thyroid nodules and lymph nodes in the lateral neck are biopsied.

The results of the biopsy help dictate the extent of operation. “After surgery, patients with papillary or follicular thyroid cancer are treated with thyroid hormone suppression therapy, and sometimes radioactive iodine. We then

SPECIALTIES: Pancreatic cancer, carcinoid tumors, thyroid cancer, adrenal tumors, parathyroid tumors, melanoma, sarcoma, gastrointestinal cancers (including colorectal, small bowel, and stomach), liver tumors.

WORK EXPERIENCE: After completing a fellowship in surgical oncology and surgical endocrinology at MD Anderson in Houston in the summer of 2011, Dr. Landry joined the staff at Banner MD Anderson.

Dr. Christine Landry Dr. Landry is a board certified surgeon who specializes in surgical oncology and surgical endocrinology. She earned her medical degree from the Texas Tech University Health Sciences Center School of Medicine in Lubbock, completed a general surgery residency at the University of Louisville School of Medicine, and fellowships in both surgical oncology and surgical endocrinology at the University of Texas MD Anderson Cancer Center in Houston.

MEDICAL SCHOOL: Texas Tech University Health Sciences Center School of Medicine, Lubbock, Texas.

INTERNSHIP: General Surgery, University of Louisville School of Medicine, Louisville, Kentucky.

RESIDENCY: General Surgery, University of Louisville School of Medicine, Louisville, Kentucky.

POST-GRADUATE TRAINING: Surgical oncology, University of Texas MD Anderson

follow the patients closely with regular ultrasounds,” Dr. Landry said.

Patients with medullary thyroid cancer are screened for genetic conditions such as multiple endocrine neoplasia type 2 (MEN 2). Genetic testing is beneficial in high-risk patients because the specific RET mutation in MEN 2 can be used to predict the MEN 2 subtype as well as the aggressiveness of medullary thyroid cancer. Likewise, family members can also be screened for the mutation and treated appropriately.

BUILDING A FULL-SERVICE CENTER Dr. Landry and her team are building a full-service endocrine center that will include a surgical team, endocrinologists, radiologists, pathologists and genetic counselors, to provide comprehensive care. “With time, we hope to develop a thyroid nodule clinic to expedite diagnosis and treatment, and offer clinical trials for patients with metastatic thyroid cancer.”

Cancer Center, Houston and Surgical endocrinology, University of Texas MD Anderson Cancer Center, Houston.

BOARD CERTIFICATION: American Board of Surgery.

PUBLICATIONS OF INTEREST:

Landry C., Grubbs E., Busaidy N., Staerkel G., Perrier N., Edeiken-Monroe B. Cystic Lymph Nodes in the Lateral Neck are an Indicator of Metastatic Papillary Thyroid Cancer.

Endocrine Practice, Mar-Apr 2011; 17(2):240-4.

Landry C., Grubbs E., Hernandez M., Hu M., Hansen M., Lee J., Perrier N. Predictable Criteria for Selective, Rather than Routine, Calcium Supplementation Following Thyroidectomy, Archives of Surgery, December 2011 (E pub ahead of print).

Landry C., Waguespack S., Perrier N., Surgical Management of Nonmultiple Endocrine Neoplasia Endocrinopathies: State-of-theArt Review. Surg Clin North Am, October 2009; 89(5):1069-89.

Landry C., Ruppe M., Grubbs E., Vitamin D Receptors and Parathyroid Glands. In Press. Endocrine Practice, Mar-Apr 2011; 17 Suppl 1:63-8.

Landry C., Grubbs E., Edeiken-Monroe B., Vu T., Kim E., Perrier, N. Parathyroid Imaging. In press for Surgical Endocrinology Handbook.

Landry C., Rich T., Jimenez C., Grubbs E., Lee J., Perrier N. Multiple Endocrine Neoplasia. In: Yao JC, Hoff PM, Hoff, AO, eds. Neuroendocrine Tumors. New York, NY: Springer; 2011:29–49. Current Clinical Oncology Series.

Landry C., and Lee J., Pancreatic Endocrine Tumors and Multiple Endocrine Neoplasia. In press, The M. D. Anderson Surgical Oncology Handbook, 5th Edition.

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What’s happening at Banner MD Anderson Cancer Center

BY DR. EDGARDO RIVERA, MEDICAL DIRECTOR

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anner MD Anderson Cancer Center has been open just about six months. In that time, we’ve treated more outpatients than originally projected and opened a variety of new programs and services. Here’s a glimpse into what’s happening at Banner MD Anderson.

RESEARCH: We have built our research structure for the cancer center and are ready to open our first protocols. Once studies open, they will be listed on our website at www.bannermdanderson. com for both physicians and patients to view. I anticipate we will be adding new clinical trials monthly now that our structure is in place. You can con-

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tact our Clinical Trials office directly at 480-256-3425.

PHYSICIANS: I am proud of the high caliber of physicians now working at Banner MD Anderson. These physicians are highly skilled and most focus on specific disease sites. For this reason, our patient intake process matches patients with the best physician for their diagnosis.

When you make a referral, or when a patient calls directly, our first step is to review the patient’s medical records. This ensures the patient is placed with the most appropriate physician for their care.

Please see the list of physicians (on page 8) for more information on their subspecialties.

CLINICAL CANCER GENETICS: Our clinical cancer genetics program will begin soon. Patients can access a genetic counselor for high risk cancer surveillance and management, and genetic testing. To make a referral to our genetic counselor, physicians can call (480) 256-3433.

DIAGNOSTIC IMAGING: Our diagnostic imaging service offers new and innovative modalities. From 4D imaging and a unique scan for parathyroid disease to interventional radiology procedures such as cryoablation and 3D Tomosynthesis for breast screening, we offer the latest screening technologies backed by highly skilled and experienced radiologists and technologists.

To schedule a patient for an imaging procedure at Banner MD Anderson Cancer Center, call Banner Health Central Scheduling at 480-684-7500.

Our ultimate goal is to provide patients with excellent cancer treatment in a healing and welcoming environment.

Please let me know if I can answer any questions about our services or assist you or your patients.

Nurses:

The heartbeat of Banner MD Anderson

A highly trained nursing staff educate patients, ease fears

BY ALISON STANTON

P

atients who arrive at Banner MD Anderson Cancer Center for the first time typically have many things in common.

Most are scared and nervous. Many have questions about their treatments.

All of them need calm reassurance.

The patients also share something in common that will make all the difference in the time they spend at the center: they will all be treated with the utmost of care and respect by the highly trained and skilled staff of oncology nurses who understand how frightening a cancer diagnosis can be.

SPECIALIZED CARE “The nursing staff has over 1,099 years of combined nursing oncology experience and 60 percent are oncology certified through Oncology Nursing Certification Corporation,” said Cathy Townsend, R.N., Chief Nursing Officer at Banner MD Anderson Cancer Center and Banner Gateway Medical Center.

“Their goal, out of all of the chaos that surrounds a cancer diagnosis and

treatment, is to try to keep things as normal for the patients as possible, by helping to keep their routines going as much as possible, so it really does not interfere with their schedules that much and they can try to lead as normal a life as they can,” she said.

Townsend said that the nurses provide specialized care in three of the center’s departments.

“In our radiation oncology department, nurses actively help to educate and put together information for the patients on the complexity of their treatment,” she said.

“For example, a patient may get 30 treatments over 30 days, and so the nurse will meet with them and discuss what those treatments will be like as well as go over any necessary prescriptions they might need. They will also handle all of the related teaching about the equipment they will use, how it will affect the patients, what side effects they might have and how it will affect their lives.”

PATIENT COMMUNICATION Over in the clinical department, Townsend said nurses are present

when the patient is first diagnosed with cancer. At this point, she said, many patients are overwhelmed, so the nurses perform the valuable service of assisting with communication with the oncologist.

“Patients don’t know what they should do or what to expect — it’s like if someone has never flown in an airplane before and will not know what will happen. It’s a similar situation with being diagnosed with cancer; how can they cope if they have not experienced it?”

From making sure cancer patients are asking the right questions or, in some cases, asking the questions for them to advocating for them throughout the entire treatment process, the nurses offer both guidance and reassurance to patients with cancer.

MANAGING CARE In the infusion department, Townsend said nurses are constantly assessing patients who are undergoing chemotherapy to help them manage any symptoms they may be experiencing.

“Nurses know how to monitor things about patients and their routines, and they know what tests and procedures the patients will be having, and when to get a physician if a patient needs extra medication or help.”

Regardless of what department the oncology nurses work in at Banner MD Anderson Cancer Center, they provide each and every patient with a welcome and predictable presence that goes a long way in helping patients feel better, both physically and emotionally.

“At our center, patients keep coming back to utilize the facility for their treatments, so the nurses build up a rapport and a bond with them. The nurses get to know their families, and they share stories with them,” she says.

“It takes a whole team to work with each patient and everyone is a valued member.”

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‘Flavor profiling’

helps in chemo treatment Executive chef tailors’ meals to patients’ taste, nutritional needs

BY GREMLYN BRADLEY-WADDELL

C

hemotherapy is a wonderful tool in the war against cancer, but as most folks know, it has some less than wonderful side effects like hair loss, fatigue and nausea.

And an overwhelming majority of patients also suffer from “taste acuity,” says Heather Metell, executive chef at Banner MD Anderson Cancer Center and Banner Gateway Medical Center in Gilbert.

“Food doesn’t taste like it’s supposed to,” she says, explaining that taste buds – like cancer cells – are a type of cell that grows quickly. Just the type that an anti-cancer treatment such as chemo is created to destroy.

As a result, Metell says, patients often find their food tastes odd: metallic-like, too salty, too sweet or just plain tasteless. And taste can vary from day to day; one day, foods taste sweet; the next, they don’t. But because maintaining one’s weight and strength is vital to be able to continue and finish chemo treatments, it’s that much more important to make sure one is getting enough sustenance, adds registered dietitian Monika Baxter, who also works at the cancer center.

All of this got Metell to thinking.

And one of her first thoughts was instead of sending food up to a patient’s room and finding out later that the food tasted wrong, why don’t we go up to their room first and ask what they can taste? Then, a meal can be tailored to their specific needs. So, that’s what Metell’s staff began doing. Armed with samples of vanilla pudding, peanut butter and lemon yogurt – foods that

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typically register to most folks as sweet, savory and sour – they meet one-on-one with patients, often before chemotherapy treatments have begun, to determine what they can taste and how it tastes. Then, if a patient can detect sourness, for example, Metell might whip up a lemon crème sauce to put atop halibut. If another patient can taste sweetness, a protein-packed Chocolate Diablo smoothie may be added to the menu.

Metell calls the process ‘flavor profiling’ and believes she and her staff are the only ones in the country doing this kind of thing in a hospital setting.

Metell calls the process “flavor profiling,” and believes she and her staff may be the only ones in the country doing this kind of thing in a hospital setting. They began this “very motherly approach,” as she calls it, after the cancer center opened in September 2011 and have worked with about 25 people thus far. Metell is also collecting data and trying to improve upon the method every day.

“So far, it’s been working out pretty well,” Metell says. “It’s challenging but pretty rewarding when you get someone nourished.”

Profile: Executive Chef Heather Metell Heather Metell has always felt at home in the kitchen, whether it was the one in her childhood home or a more commercial variety.

“I was washing dishes at a little inn at 12 years old,” says the executive chef, who now oversees a staff of about 50, including dietitians, cooks and dishwashers, at Banner MD Anderson Cancer Center and Banner Gateway Medical Center in Gilbert.

Originally from Massachusetts, Metell made her living for years in the kitchens of some of the finest East Coast resorts.

And while she ditched the country-club atmosphere and its stressful demands when she moved to Arizona – she yearned for a more relaxed lifestyle, one in which she didn’t have to put in “90 hours a week” – the elegant and refined approach to food she had mastered during her years on the resort scene is evident in the menu offerings she now serves up for patients.

“It’s been a bit of a challenge to make the food taste good without salt or fat,” says Metell, whose culinary passion is making sauces. “But we’re probably one of the only hospitals that makes its own veal demi-glacé.”

Partial breast radiation treatment

speeds recovery Recent improvements ease concerns, risks

BY ALISON STANTON

T

hanks to a procedure called partial breast radiation treatment, some breast cancer patients at Banner MD Anderson Cancer Center are able to have just one week of radiation after a lumpectomy, instead of the traditional six weeks.

“The radiation is focused on the breast tissue just around the area of the lumpectomy site, and we do the procedure soon after surgery for an accelerated period,” said Dr. Matthew Callister, radiation oncology section chief at Banner MD Anderson, adding that the treatment has been offered at the center for some time.

“The advantages of this treatment are that in addition to a significant reduction of the amount of time a patient has to receive radiation, the whole breast is not exposed to the radiation but rather just the treatment bed or tissue around it.”

Over the last few years there have been significant improvements in the partial breast radiation treatment, Callister said, including in the devices that are placed in the breast to deliver treatment in a conformal way.

“We are able to customize the doses better with this treatment,” Callister said.

Although a recent abstract that was presented by colleagues at The University of Texas MD Anderson

Cancer Center in Houston and which looked at the earlier years of the technique raised concerns about its effectiveness and risks, Callister said he feels any negative side effects of the treatment can be avoided with a combination of preparation and prudence.

The advantages of this treatment are that in addition to a significant reduction of the amount of time a patient has to receive radiation, the whole breast is not exposed to the radiation but rather just the treatment bed or tissue around it.

– Dr. Matthew Callister “I think the study provides us with important cautions to oncologists to consider before doing a partial breast radiation treatment; for example, to properly select appropriate patients for this procedure, so we are giving it to the right ones and attending to how the treatment is given.”

Despite the findings, Callister said Banner MD Anderson Cancer Center still offers the partial breast radiation treatment to many breast cancer patients, as do his colleagues in Houston.

Dr. Matthew Callister Section Chief, Radiation Oncology SPECIALTY: The treatment of cancer with radiotherapy RECENT WORK EXPERIENCE: Assistant professor of radiation oncology and a consultant in the department of radiation oncology at Mayo Clinic Scottsdale.

MEDICAL SCHOOL: Duke University School of Medicine, Durham, N.C. INTERNSHIP: Mayo School of Graduate Medical Education, Scottsdale RESIDENCY: University of Texas MD Anderson Cancer Center, Houston BOARD CERTIFICATION: American Board of Medical Specialties AFFILIATIONS: American Society for Therapeutic Radiology and Oncology; American Society of Clinical Oncology; Children’s Oncology Group

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Introducing Banner MD Anderson Physicians

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anner MD Anderson Cancer Center 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, call 480-256-3433.

To contact a member of the medical staff, call 480-256-6444 and ask for the physician to be paged.

HEMATOLOGY & MEDICAL ONCOLOGY

ONCOLOGY SURGERY

Tomislav Dragovich, MD, PhD, Section Chief

Gynecologic Oncology

Digestive tract cancers including colorectal, esophageal, stomach, pancreatic, hepatobiliary

Shakeela Bahadur, MD

Lung, colorectal, breast cancers

Mary Cianfrocca, DO

Breast cancer Breast Cancer Program Director

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

Judith K. Wolf, MD, Section Chief Mark Gimbel, MD

Melanoma, sarcoma, cancer of the stomach, small bowel, colon and rectum, thyroid, pancreas, liver, breast, and other rare cancers

Christine Landry, MD

Pancreatic cancer, carcinoid tumors, thyroid cancer, adrenal tumors, parathyroid tumors, melanoma, sarcoma, gastrointestinal cancers, breast cancer, liver tumors

Diljeet Singh, MD

Program Director, Gynecologic Oncology

Benny Tan, MD

Plastic and reconstruction surgeon Breast cancer reconstruction and most forms of cancer reconstruction

Edgardo Rivera, MD, Medical Director

RADIATION ONCOLOGY

Bryan Wong, MD

Gastrointestinal, Skin, Sarcomas, and Head and neck cancers

Breast cancer

Genitourinary cancers

Matthew Callister, MD, Section Chief

Emily Grade, MD

Breast treatment including partial breast brachytherapy, prostate brachytherapy, gynecological and thyroid cancers

Terence Roberts, MD, JD

Brain, lung and prostate tumors; stereotactic radiosurgery; partial breast brachytherapy

DIAGNOSTIC IMAGING Donald Schomer, MD, Section Chief, CAQ Neuroradiology Oncologic diseases of the brain, spine, head and neck

John Chang, MD, PhD

Advanced magnetic resonance and computerized tomography imaging of gastrointestinal and genitourinary systems; imaging guided biopsies

Vilert Loving, MD

Breast imaging and intervention

Harvinder Maan, MD, CAQ Neuroradiology

Director of Neuroradiology Neuroradiology and interventional spine procedures

Rizvan Mirza, MD

Abdominal and pelvic magnetic resonance imaging

Susan Passalaqua, MD

Director of Nuclear Medicine and Molecular Imaging Board Certified in Nuclear Medicine and Radiology Oncologic Imaging, PET/CT

Andrew Price, MD, CAQ Interventional Radiology

Interventional radiology, including percutaneous tumor ablation, chemoembolization, and radioembolization

David Russell, MD, FACP

Breast imaging and intervention

CRITICAL CARE Shiva Birdi, MD, Section Chief John Jijo, MD Deven S. Kothari, MD Dean Prater, MD Anthony Sado, MD

INTERNAL MEDICINE David Edwards, MD

Suspicion of Cancer Clinic

Ronald Servi, DO

Pulmonary Medicine