Banner MD Anderson Rounds - June 2012

A PUBLICATION FOR COMMUNITY PHYSICIANS

JUNE 2012

View to a cure

Cutting-edge imaging tools offer women more choices — and chances — in the fight against breast cancer

BY MICHELLE TALSMA EVERSON

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hen a patient is first diagnosed with breast cancer — or even suspects the disease — there are often more questions than answers. However, through Banner MD Anderson Cancer Center’s comprehensive breast cancer program and its top-of-the-line screening and diagnostic imaging tools, women are able to get their questions answered and rapidly be on the road to treatment if necessary.

“Patients with breast symptoms are frequently and justifiably worried, but when we explain our imaging findings to them or explain what to expect during a diagnostic procedure, it results in a less intimidating experience,” says Dr. Vilert Loving, a board-certified radiologist who specializes in breast imaging and diagnosis at Banner MD Anderson Cancer Center.

Loving explains that the Women’s Imaging Center at Banner MD Anderson has a myriad of screening and diagnostic tools available to patients seeking everything from annual screening mammograms to diagnostic testing and procedures.

3D TOMOSYNTHESIS 3D tomosynthesis, commonly known as a 3D mammogram, is one of the imaging center’s latest tools—the FDA just approved its clinical use last year.

“3D tomosynthesis examines the breast from multiple, different view-

Dr. Vilert Loving stands by the 3D Tomosynthesis equipment. It is the newest imaging technology for screening mammograms.

INSIDE 3 Know the code

6 Effective surgical techniques for melanoma

4 What’s Happening at Banner MD Anderson

7 Changing the way doctors treat cancer

Cancer Center 5 Advancing the treatment of cancer

8 Introducing Banner MD Anderson physicians

points,” Loving says. “A conventional mammogram looks at the breast from two viewpoints, while the 3D tomosynthesis shows multiple angles by moving in an arc around the breast.

This provides the radiologist with more information and confidence in finding abnormalities.”

While the most effective use of the 3D tomosynthesis is still being decided, Loving said that the center has so far found it most useful for women seeking routine screening mammograms to distinguish normal overlapping breast tissue from true abnormalities. It has also been helpful to fully characterize disease in some patients’ diagnostic mammograms.

He adds that the center has the only 3D mammogram he knows about in the East Valley and one of the few in the state.

BREAST MRI Another stand out series of instruments that help patients to prevent or detect cancer are the center’s MRI tools.

In addition to MRI biopsy, the Women’s Imaging Center utilizes advanced MRI technology to screen high risk patients or to evaluate cancer in patients who have already been diagnosed, according to Loving.

“In general with MRI, the stronger the magnet, the better the image. We have a 3T magnet which is the best that is clinically available. Many centers employ a 1.5T magnet or lower,” Loving says. “Our MRI images are very good; they are better than a mammogram for finding breast cancer. MRIs are best used for screening higher risk patients and in some patients who already have a cancer diagnosis to determine the full extent of disease in the breast.”

Loving adds that, while the images taken by a high-powered MRI are often “noisier” (meaning harder to read), Banner MD Anderson works closely with a physicist to clear the noise

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Comprehensive care for breast cancer patients Banner MD Anderson Cancer Center’s Comprehensive Breast Cancer Program provides the full range of medical care and support needed with a breast cancer diagnosis. The medical team includes medical oncologists, breast surgeons, reconstruction surgeons, radiation oncologists, radiologists and additional clinical and support staff. The program also offers beneficial support services to women in every stage of their breast cancer treatment.

Mary Cianfrocca, D.O., F.A.C.P., the director of the breast cancer program, says that support services help to “provide better care in the long run.” Some of these services include: Dr. Mary Cianfrocca, director of the breast cancer program. and maximize the picture — meaning clearer images and better patient results.

DIGITAL MAMMOGRAPHY AND DIAGNOSTIC TOOLS The Women’s Imaging Center also utilizes digital mammography, which is similar to traditional mammography, but provides a crisp digital image.

“Digital mammography has been shown to be advantageous for younger people in their 40s,” Loving says.

In addition to state of the art imaging technology, the center offers a wide array of diagnostic tools, including: different types of biopsies (ultrasound guided, stereotactic and MRI), breast ultrasound, cyst aspiration, needle localization, lymph nodes biopsy, and more.

To refer a patient to Banner MD Anderson for a screening mammogram or more extensive diagnostic testing, please call (480) 543-6900. Patients may also call this number directly to schedule an appointment.

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Undiagnosed Breast Clinic, for women who may have an abnormal finding but do not have a confirmed cancer diagnosis Clinical nurse navigators who lead patients through the system of care Wellness activities and support groups Clinical Cancer Genetics Program The Boutique of Hope, which helps women who have undergone mastectomies or other treatments to feel better about themselves Lymphedema therapy, which helps to reduce lymphatic swelling during treatment Palliative care, which can help patients manage pain Other unique offerings like nutritionists and weight loss programs for breast cancer survivors

“The wonderful thing about these support programs is the ability to offer so many diverse services in one location with the ultimate goal of caring for the whole person.” Cianfrocca says.

To learn more, visit BannerMDAnderson.com.

Physician Phone Numbers Schedule a mammogram – 480-543-6900 Undiagnosed Breast Clinic – 480-256-3433 Refer a patient – 480-256-3433

Know the code

Genetics program offers new insights into screening for and treating cancer

BY JAKE POINIER

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he Human Genome Project was completed in 2003, but The University of Texas MD Anderson Cancer Center had begun integrating genetics into care plans for cancer patients in the mid 1990s, when two breast cancer genes, BRCA1 and BRCA2, were discovered. With other cancer genes subsequently identified, the understanding of the relationship between cancer and our genetic code has continued to progress—with implications for screenings as well as treatment. The longstanding work in genetics in Houston is now benefitting patients in Arizona at Banner MD Anderson Cancer Center.

“There are primarily two populations of patients we see in our clinic,” said April O’Connor, a certified genetic counselor and the genetics program coordinator of the Banner MD Anderson Clinical Cancer Genetics Program in Gilbert. “Those who currently have cancer, and those who are healthy but concerned about their cancer risk.”

The clinic’s goal is to determine whether there is a hereditary predisposition to a patient’s cancer—which occurs in about 5 to 10 percent of cases—or if it is sporadic. The distinction is critical: Hereditary cancers may react differently to treatment, and be more aggressive, which could change the protocol for treatment options.

“If someone has hereditary breast cancer, they have a much higher chance of recurrence in the other breast, about 40 to 60 percent,” O’Connor said. “If it’s sporadic cancer, then it’s only 2 to 10 percent. It makes a difference in whether you’d consider a prophylactic mastectomy of the other breast, versus just monitoring by screening.”

April O’Connor, cooridinator of Banner MD Anderson Cancer Center’s Clinical Cancer Genetics Program.

GENES AND SCREENS Screening protocols for people with a genetic predisposition for breast cancer have changed in recent years as well.

Mammograms once a year for individuals over 25, or individualized based on the youngest cancer diagnosis in the family, now can be supplemented every six months with MRI scans for improved detection.

Colon cancer is another case in which genomics also may affect the screenings. A full colonoscopy will likely take place earlier, around age 20-25, to assess for any polyps or cancers.

While genes that cause ovarian cancer are known, diagnosis is more difficult because the ultrasound and blood test screening results are not as definitive, and the tumors are often fast growing.

TESTING, TESTING Prior to any testing, genetic counseling thoroughly examines family and

personal history. Taking into account cancer at early age, rare forms such as male breast cancer, or two different types of cancer in the same individual, clinicians look at risk models that indicate the likelihood of a genetic mutation. If testing is performed, the results come in within two to three weeks.

Although genomics has come a long way in the past two decades, there are still gray areas, since not every cancercausing gene has been identified. “You’re not always going to get a definitive answer,” said O’Connor. “But even if you learn you’re negative for the most likely gene, you’ve checked something significant off the list of possible causes.”

Reading your genes To refer a patient to the Clinical Cancer Genetics Program at Banner MD Anderson Cancer Center, please call (480) 256-3433.

Patients may also self refer by calling (480) 256-6444.

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What’s Happening at

Banner MD Anderson Cancer Center

BY DR. EDGARDO RIVERA, MEDICAL DIRECTOR

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e have reached the six month mark since the opening of Banner MD Anderson Cancer Center.

And it has been a busy six months! I am pleased to share that we have more than 60 physicians now working with the cancer center, each highly specialized in their fields of expertise.

We have established several comprehensive disease specific programs.

In this issue of Rounds, you will read about our Comprehensive Breast Cancer Program. This program encompasses all aspects of breast cancer, from prevention and diagnosis to treatment and support. Our team of physicians includes radiologists, medical oncologists, breast and reconstruction surgeons,

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radiation oncologists and pathologists.

They are supported by an excellent nursing and support staff, and the latest in diagnostic and treatment modalities.

In the Undiagnosed Breast Clinic, women with a suspect mass or an abnormal mammogram receive further evaluation to determine the presence or absence of a malignancy. This diagnostic process is accelerated to provide a timely diagnosis, often with 24 to 48 hours. We hope this will reduce anxiety for many women, and will assist you with expedited diagnoses for your patients.

This issue also features our melanoma team. A medical oncologist and surgical oncologist work together to provide the latest treatment options for people diagnosed with melanoma.

We continue to welcome new physicians to our

cancer center. Most recently we have welcomed Dr. Diljeet Singh, a gynecologic oncologist who is developing our prevention and integrative medicine program. Finally, we have begun to open clinical trials for our patients. We are participating in a breast cancer trial, and will be opening trials for chronic lymphocytic leukemia, colorectal and pancreatic cancers shortly. A number of additional trials are currently in the review process. In addition, we are developing a process to offer selected trials from The University of Texas MD Anderson Cancer Center in Houston on our campus. This will give Arizona patients access to many more clinical trial opportunities.

As always, please contact me if you have any questions about Banner MD Anderson Cancer Center or referring a patient. I can be reached at (480) 256-3335.

conference with the physicians at The University of Texas MD Anderson Cancer Center in Houston.

“We are constantly talking about our cases as a community,” she says.

“It’s the idea of having collective minds working together and pooling our brain power that makes a big difference here, even more so than the best equipment.”

SPECIALIZED TREATMENT

Dr. Emily Grade, a radiation oncologist at Banner MD Anderson Cancer Center.

Advancing the treatment of cancer

Oncologists at Banner MD Anderson Cancer Center meet regularly to discuss their patients and compare charts, notes and ideas

BY ALISON STANTON

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s a radiation oncologist at Banner MD Anderson Cancer Center, Emily Grade, M.D., has access to the most advanced and state-of-the-art equipment in the world. The cancer center was built with careful planning to provide excellent care and a positive patient experience. In addition, everything a patient might need is provided in one location.

Grade also knows that while having access to the best equipment is essential, it is just as important to have regular communication

with the other treating physicians about the health, treatment and care of each and every patient.

TEAM APPROACH “I came here from a community practice, and when I arrived, the first thing I noticed was how the entire team of doctors communicates regularly and works together to help our patients,” she says.

In addition to meeting with the team of doctors at the Gilbert facility twice a week, Grade says the radiation oncologists meet via a regular phone

In addition to the “many heads are better than one” approach to patient care, Grade says another way the center is advancing the treatment of cancer is by specialization. In other words, the doctors focus on specific cancers and become experts in that cancer treatment. This specialization is done similarly at MD Anderson in Houston.

While Grade appreciates being part of a medical team that values communication, sharing patient information, and working collaboratively to be sure that each and every patient is given the best treatment possible, she says the state-of-the-art oncology equipment does definitely help them in their work.

“Delivery of radiation has become more sophisticated. Here we can now pinpoint very accurately where we are delivering the dose, and we can avoid nearby organs and healthy tissue more easily,” she says.

“We can also choose to utilize a PET scan as part of the therapy treatment design, so we can see where the cancers are active and where they are not.” This would allow the field of treatment to be more accurate.

The Radiation Oncology department provides a wide array of radiation treatments with the latest technologies. Physicians may refer patients for radiation treatment by contacting the radiation oncology department at (480) 256-4500.

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Effective surgical

techniques for melanoma Banner MD Anderson oncologist recommends an aggressive approach

BY STEPHANIE CONNOR

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ith shorts and tank-top season upon us, it’s incumbent upon primary care physicians and dermatologists to check patients for melanoma and other skin cancers.

“Once a melanoma is identified,” says Mark Gimbel, M.D., a surgical oncologist at Banner MD Anderson Cancer Center who specializes in cutaneous tumors,

“physicians should be appropriately aggressive in their surgical approach.”

Gimbel offers a few reminders for treating melanoma.

First, he says, Mohs surgery isn’t appropriate for melanoma, so reserve that technique for basal and squamous cell carcinomas. Because melanoma requires a wider margin, he says, Mohs surgery could result in missing part of the cancerous tissue or any satellite lesions.

IMPORTANCE OF MARGINS Second, make sure the margins around the melanoma are wide enough. “If the margins aren’t wide, there’s a higher chance of residual disease and an increased likelihood of local recurrence,” Gimbel says.

Treating melanoma surgically, he explains, requires an aggressive approach.

“The size of the excision is based on the depth of the tumor,” Gimbel says.

“The deeper the tumor into the skin, the wider the excisional margin needs to be.”

He offers this example: “A melanoma could be up to 1 mm in depth. You need a 1 cm margin. So, that could end up being an excision that’s 2½ cm in diameter.”

Because particularly wide excisions can be disfiguring, he says that orienting the original biopsy or excision appropriately for the area is essential.

BEYOND THE EXCISION

Banner MD Anderson physicians Dr. Mark Gimbel, (left) surgical oncologist, and Dr. Jade Homsi, medical oncologist, specialize in the diagnosis and treatment of melanoma. They work as a team to provide a multidisciplinary approach to treating the disease.

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“We also have to look at the pathologic evaluation of the tumor,” Gimbel says.

By looking at the thickness, ulceration and the mitotic rate of the tumor, pathologists can effectively stage the primary melanoma.

It’s also essential to evaluate the regional lymph nodes if the melanoma grows beyond a specific depth. The risk of spread to the lymph nodes increases as the depth of the melanoma increases.

Typically, for melanomas greater than one millimeter in depth, a lymph node evaluation is recommended. For lymph nodes that can be palpated a full nodal dissection is performed. However, for patients without palpable nodes, instead of removing all of the lymph nodes in a regional basin (axilla/neck/groin), only one or two sentinel nodes are removed at the time of the initial surgery to see if the melanoma has spread.

Still, Gimbel says, with all the advances in treating melanoma, the most important thing for any doctor is to help catch it early.

Changing the way doctors treat cancer Banner MD Anderson Cancer Center to introduce new prevention and integrative medicine program

BY GREMLYN BRADLEY-WADDELL

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hen it debuts this fall at Banner MD Anderson Cancer Center, the Cancer Prevention and Integrative Medicine program will take a “whole person, whole patient” approach to healthcare, says Diljeet Singh, M.D., DrPH.

NEW WAY OF THINKING For some, the “integrative” approach may be a new way of doing things, says the newly minted program director at the Gilbert hospital, where she also serves as program director of gynecologic oncology. That’s because traditional, Western-based allopathic medicine tends to focus on diseases, diagnoses and treatments and often does not take much else, like a person’s lifestyle, into consideration. In her first-floor clinic, however, Singh and her staff will take the time to educate the public about healthy living and disease prevention and, when treating cancer patients, incorporate – integrate, in other words – the myriad factors that affect wellness, like nutrition, stress and physical activity.

“And, if you are someone who does not have any diagnoses, it’s our job as physicians working in prevention and integrative medicine to ask, ‘How do we keep you that way?’ ” Singh adds.

ABOUT DR. SINGH An energetic type who studied under the well-known physician Andrew Weil at his Arizona Center for Integrative Medicine

Dr. Diljeet Singh heads up Banner MD Anderson Cancer Center’s Prevention and Integrative Medicine Program. at University of Arizona in Tucson, Singh recently relocated to the Valley from Chicago and the Robert H. Lurie Comprehensive Cancer Center of Northwestern University. She held an academic appointment as assistant professor of Obstetrics and Gynecology at Northwestern University Feinberg School of Medicine and was a co-director of the Northwestern Ovarian Cancer Early Detection and Prevention Program.

As for her training, Singh earned her medical degree from Northwestern University and a master’s in public health from Harvard University School of Public Health. She completed her residency in obstetrics and gynecology at the Johns Hopkins School in Balti-

more, followed by three years’ worth of fellowship training in gynecologic oncology at The University of Texas MD Anderson Cancer Center in Houston.

Her doctoral degree in cost analysis is from The University of Texas School of Public Health.

CONCENTRATED CARE Singh envisions the clinic as a welcoming place for cancer patients to get an integrative medical consultation and to see any one they need: a doctor, nutritionist, physical or rehabilitation therapist, social worker or psychologist. Some of the modalities she expects the clinic to offer include Eastern medicine, massage and acupuncture, all of which she says have benefits when used and managed properly.

“For example, we’ve proven acupuncture decreases chemotherapyrelated nausea, equal to the amount that a drug can, and with fewer side effects,” she says.

On the prevention side, she says the clinic will be a place where cancer survivors can learn about their future health risks and ways to avoid further disease. Those not affected by the disease can also benefit from the clinic by getting a health assessment based on family history and genetics and by learning about behaviors that put them at risk for the disease.

SAFE TREATMENT While she knows holistic medicine has gotten some bad press, Singh makes it clear that the Banner clinic won’t offer treatments that haven’t proven to be effective and will run clinical, safety and efficacy trials on any new treatment before it is even considered for use. If anything, the local medical community has truly embraced the clinic – and she wouldn’t expect otherwise.

“I think everybody in medicine is for doing everything we can for people,” she says.

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PRESORTED STD U.S. POSTAGE PAID LONG BEACH, CA PERMIT NO.1677

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, 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

ONCOLOGY SURGERY SECTION

RADIATION ONCOLOGY SECTION

Tomislav Dragovich, MD, PhD, Section Chief Digestive tract cancers including colorectal, esophageal, stomach, pancreatic, hepatobiliary

Judith K. Wolf, MD, Section Chief Gynecologic oncology

Matthew Callister, MD, Section Chief Gastrointestinal, skin, sarcomas, and head and neck cancers

Shakeela Bahadur, MD Lung, colorectal, breast cancers Mary Cianfrocca, DO Breast Cancer Program Director Jade Homsi, MD Melanoma, sarcoma, immunotherapy

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

H. Uwe Klueppelberg, MD, PhD Multiple myeloma and other plasma cell disorders, lymphomas, myelodysplastic syndrome, brain cancers, head and neck cancers, thoracic cancers

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

Edgardo Rivera, MD, Medical Director Breast cancer

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

Kerry Tobias, DO Pain management, palliative medicine, physical medicine, rehabilitation

Stephanie Byrum, MD Breast surgery

Bryan Wong, MD Genitourinary cancers

Rob Schuster, MD General surgery Al Chen, MD General surgery

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 SECTION 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 Oncologic imaging, nuclear medicine, radiology, 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 SECTION Shiva Birdi, MD, Section Chief John Jijo, MD Deven S. Kothari, MD Dean Prater, MD

INTERNAL MEDICINE SECTION Nikunj Doshi, DO, Section Chief Internal medicine David Edwards, MD Internal medicine Ronald Servi, DO Pulmonary medicine

PATHOLOGY SECTION Kevin McCabe, DO Section Chief