care
CANCER
for anyone touched by cancer SPRING 2018
ALSO IN THIS ISSUE
A surgeon’s magical touch page 5 Breast cancer caught early page 7
A child’s battle
page 4
When water molecules become destroyers page 10 What you need to know about molecular diagnostics back cover
Capitalizing on cancer’s sweet tooth page 15
Brought to you by the
How to make your first appointment
YOUR GUIDE
REQUESTING AN APPOINTMENT with the experts at the Upstate Cancer Center is easy. Our team of board-certified physicians and oncologycertified nurses and technicians is prepared to offer timely appointments, second opinions, screening tests and personalized treatment plans. To make your first appointment, either call 855-964-HOPE (4673) or visit upstate.edu/cancer and click on “request appointment.” e cancer center team strives to respond to each request within 24 hours. Upstate University Hospital also offers a free and confidential referral service for people who are looking for medical providers. MD Direct provides information and can help set up appointments with Upstate physicians. If an Upstate provider does not meet your needs, MD Direct can give you information about other appropriate providers in Central New York. Physicians and providers do not pay for referrals or to participate in the referral service. Reach MD Direct by calling 315-464-4842 or 800-544-1605. ●
PHOTO BY WILLIAM MUELLER
The National Stroke Association reports that African-Americans are twice as likely to die from stroke as Caucasians. The statistics than any other group. Know your risk.
STROKE RISK FACTORS • HIGH BLOOD PRESSURE: It's the No.1 cause.
• DIABETES
• OBESITY
• SMOKING: Increases risk by two to three times.
A STROKE IS A BRAIN EMERGENCY. IF YOU SUSPECT A STROKE, CALL 911 AND ASK FOR UPSTATE.
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CANCER CARE
Comprehensive Stroke Center
upstate.edu/cancer l spring 2018
INSIDE
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15
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Inside this issue CARING FOR PATIENTS
SEARCHING FOR CURES
How to request an appointment
page 2
A child’s battle
page 4
Her surgeon had a “magical” touch
page 5
Why robotic surgery might be part of your treatment
page 6
Catching breast cancer early
page 7
Connecting pediatric cancer families page 17
Palliative care helps her live with cancer
page 8
Recipe: Chicken and White Bean Soup
SHARING EXPERTISE
What you need to know about molecular diagnostics
back cover
Capitalizing on cancer’s sweet tooth
page 15
LIVING WITH CANCER
page 18
MAKING A DIFFERENCE
Microwave technique turns water molecules into destroyers
page 10
5 reasons a team treats gastric, esophageal cancers
page 12
How about a career in clinical laboratory science?
page 14
More than 20 years of helping
page 19
On the cover: Fahima Farah, age 5. See story, page 4. PHOTO BY SUSAN KAHN
care
CANCER
for anyone touched by cancer
SPRING 2018
CANCER CARE
UPSTATE CANCER CENTER
EXECUTIVE EDITOR Leah Caldwell Assistant Vice President, Marketing & University Communications
DIRECTOR (INTERIM) Jeffrey Bogart, MD
MANAGING EDITOR
Amber Smith 315-464-4822 or smithamb@upstate.edu
WRITERS
Leah Caldwell Jim Howe Susan Keeter Amber Smith
DESIGNER
Susan Keeter
The Upstate Cancer Center provides the quarterly magazine Cancer Care for anyone touched by cancer. Send subscription requests and suggestions to magazine@upstate.edu and request additional copies by calling 315-464-4836. Cancer Care offices are located at 250 Harrison St., Syracuse, NY 13202.
spring 2018 l upstate.edu/cancer
DEPUTY DIRECTOR (INTERIM) Gennady Bratslavsky, MD ASSOCIATE DIRECTOR FOR CLINICAL RESEARCH Stephen Graziano, MD ASSOCIATE DIRECTOR FOR BASIC AND TRANSLATIONAL RESEARCH Leszek Kotula, MD, PhD ASSOCIATE DIRECTOR FOR COMMUNITY OUTREACH Leslie J. Kohman, MD ASSOCIATE ADMINISTRATOR Richard J. Kilburg, MBA
The Upstate Cancer Center is part of Upstate Medical University in Syracuse, N.Y., one of 64 institutions that make up the State University of New York, the largest comprehensive university system in the United States. Upstate Medical University is an academic medical center with four colleges, a robust biomedical research enterprise and an extensive clinical health care system that includes Upstate University Hospital’s downtown and Community campuses, the Upstate Golisano Children’s Hospital and many outpatient facilities throughout Central New York — in addition to the Upstate Cancer Center, which is located at 750 E. Adams St., Syracuse, NY 13210.
CANCER CARE
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A new home, a difficult diagnosis
CARING FOR PATIENTS
explained Caruso Brown. “First, there was the nature of the cancer and the complexity of treatment — radiation is especially difficult to translate because it’s invisible. She wanted to understand our medical system and human anatomy. We needed to help Fahima’s mom grasp what the next year and a half of their lives would be like.’’
Fahima was hospitalized at the Upstate Golisano Children’s Hospital for much of 2014. anks to a sleeper couch in her room, her mother and baby sister were able to stay with her. During that time, Warsame was studying for her citizenship exam and learning English. e complex medical needs of a child like Fahima underscore the importance of Upstate’s role in the care of children who are new to this country. In addition to her multidisciplinary oncology team, Fahima has access to dental and primary care at Upstate.
Pediatric oncologist Amy Caruso Brown, MD, with Fahima Farah BY SUSAN KEETER
FAHIMA FARAH WAS 2 when her mother, Khadra Warsame, brought her to Upstate’s emergency department for stomach pain. A CT scan of her belly showed a mass. Six years earlier, her family — who are Somali — immigrated to Syracuse from a refugee camp in Kenya. Fahima was born in Syracuse, as was her younger sister, Ayaan. ey are patients at Upstate’s Pediatric and Adolescent Center, as are most children of refugees in Syracuse.
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For nearly 15 years, Upstate has been the principal medical referral site for refugees, adding 200 to 300 new refugee children as patients each year. Pediatrician Andrea Shaw, PHOTO BY SUSAN KAHN MD, leads the program and meets monthly with InterFaith Works and Catholic Charities, the two agencies in Syracuse that support much of refugee resettlement. Her colleague, resident physician Elizabeth Paulsen, MD, is the primary care doctor for Fahima and her siblings. In addition to providing crucial medical care to a vulnerable population, working with refugees provides invaluable training for Upstate’s 43 pediatric residents and 1,312 students.
Fahima was diagnosed with neuroblastoma, a type of cancer that starts in certain, very early forms of nerves found in an embryo or fetus. Chemotherapy, followed by surgery, a second round of high-dose chemotherapy, harvesting and transplant of her stem cells and months of immunotherapy were necessary to treat this very aggressive cancer, which has a 50- to 60-percent survival rate.
“I teach about conditions prevalent in people who have fled persecution — infectious diseases, malnutrition, trauma and under-managed chronic diseases,” explains Shaw. “Aer arrival, children have layers of needs. Our students and residents have a unique opportunity to learn from these families and raise their level of cultural awareness and ability to advocate for the needs of this population.”
e day of diagnosis, an interpreter, surgeon Jennifer Stanger, MD, and oncologist Amy Caruso Brown, MD, met with the mother and child. “ere was so much Fahima’s mother needed — and wanted — to understand,”
Aer a year and a half of being in remission, Fahima, now age 5, recently relapsed and is undergoing further treatment for neuroblastoma. She is in kindergarten, and her mother has become a U.S. citizen. ●
CANCER CARE
upstate.edu/cancer l spring 2018
Meet the ‘magic man’
CARING FOR PATIENTS
Surgeon’s demeanor, outlook help patient beat slim odds BY AMBER SMITH
MELANOMA OF THE RECTUM is rare and aggressive, and its prognosis is poor. e majority of people with the diagnosis don’t survive more than 24 months.
Bem knew Downey’s situation was dire. e surgery she needed — an extensive oncological resection — would be challenging, and it might not work.
To Jiri Bem, MD, that’s no reason to give up.
But it might.
A 59-year-old woman from Clayton was having pain when she had bowel movements. She went for a colonoscopy. at screening revealed melanoma of the rectum. Her doctor sent her to Memorial Sloan Kettering Cancer Center in New York City.
If they decided to take the chance, they might see amazing results.
Doctors there were reluctant to operate, recalls Billie Downey. “ey pretty much said I had more than a 98-percent chance of dying. So, I went to Upstate, and I just liked the people there better.” at was in 2011. Downey is 66 today. She defied the odds. She survived melanoma of the rectum. “He’s definitely my magic man,” she says in crediting Bem, her colorectal surgeon. When she returned from New York City, Downey underwent three months of chemotherapy at Upstate to shrink the tumor. en her oncologist made an appointment with Bem, who sees patients in Alexandria Bay every two weeks.
Downey says Bem told her the same thing the doctors at Memorial Sloan Kettering did regarding survival odds. Bem was straight with her. It would be a major surgery, with no guarantee of success. e tumor was in a bad spot, and it was growing. To remove it would mean removing her rectum. She likely would be in intensive care for a week, and it would take several weeks for her to heal. He would be willing to try to help her, if she wanted him to. “He was more hopeful,” Downey remembers. “e tone of his voice is very comforting, too.” She went ahead with the surgery. As predicted, recovery took a while. She learned about her ostomy, which would take over the functions of her rectum. “You learn it, and you accept it, and you just move on.” at was 6 ½ years ago. Downey remains free of cancer. She sees Bem once a year. ●
Colorectal surgeon Jiri Bem, MD, talks with his patient Billie Downey. Downey has follow-up appointments with him close to her home in Clayton. PHOTO BY SUSAN KAHN
spring 2018 l upstate.edu/cancer
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CARING FOR PATIENTS
3 reasons your doctor might recommend robotic surgery From left, urologists Gennady Bratslavsky, MD, Oleg Shapiro, MD, and Rakesh Khanna, MD, in one of the robotic surgery suites. Upstate has 13 robotically trained urologic surgeons, performing the highest volumes in the region. Other distinctions include the region’s first thoracic and hepatobiliary robotic surgery teams, to treat cancer and PHOTO BY SUSAN KAHN other conditions involving the chest, liver, gallbladder and pancreas.
BY LEAH CALDWELL
DEPENDING ON the type of cancer and its stage, your care plan may include surgery. Robotic surgery is one type of minimally invasive surgery. e surgeon uses a flexible scope with a camera and blade and views the site through a monitor, rather than doing the procedure over the patient. “For patients who are not familiar with the technology, we explain that the robot is a tool that gives us special capabilities. It does not perform the surgery—the surgeon is always in control,” explains Mark Crye, MD, a thoracic surgeon who treats lung cancer and other conditions.
Here are three reasons your cancer care team may recommend robotic surgery: 3-D VIEW e camera provides a 3-D visualization of the area. When that image is magnified on the monitor, it allows the surgeon to operate in very tight spaces with a good view and great dexterity. e robotic instruments mimic the human hand and wrist. “at really allows us the freedom to operate on very delicate structures, explains Crye. PATIENT COMFORT Robotic surgery uses a very small incision site and tiny instruments, so patients oen are able to return to regular activities sooner. But having a surgery team close to home provides an additional type of comfort, beyond the
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physical. “We see our patients through the entire course of their treatment, whether it’s days, weeks or longer. If a surgery patient needs follow-up, they can be seen quickly by us and not have to be far from their family or home,” adds Ajay Jain, MD, who treats complicated stomach, liver, gallbladder and pancreatic cancers using robotic surgery. EXPERIENCE Some types of cancer treatments increasingly are performed with robotic surgery, but the use of the tool is in concert with the surgeons’ skills. e Upstate Cancer Center has both developed its robotic capability and brought in new faculty with the expertise. “Cancer care is complex, and that’s why American Board of Surgery has recognized surgical oncology as a separate specialty,” explains Mashaal Dhir, MD, who is board certified and fellowship trained in both complex general surgical oncology and endocrine surgery, and also robotically trained. Of note: e words “board certified” and “fellowship
trained” indicate that a doctor has passed rigorous tests to national standards (“the boards”) and has performed years of training (“a fellowship”) in addition to a standard medical residency. ● Hear more at healthlinkonair.org. Search “Robotic”
upstate.edu/cancer l spring 2018
Catching it early
CARING FOR PATIENTS
Breast cancer high-risk program follows patients at increased risk BY AMBER SMITH
BOTH HER GRANDMOTHER AND MOTHER had breast cancer, so Jordan Bruna of Skaneateles began breast cancer screening at the age of 30. She joined Upstate’s Breast Cancer High Risk Program and followed a schedule of mammograms, ultrasounds, magnetic resonance imaging and clinical exams spaced throughout each year. Bruna’s breast tissue was dense and fibrous, like that of her matriarchs. When breast imaging revealed anything suspicious, she was sent for a biopsy. She remembers results being normal — the first three times. Bruna had just turned 40 when her breast cancer was discovered. “I knew what treatment I would want. I really felt incredibly confident from the beginning,” she says. Her grandmother was diagnosed at age 80 with an advanced breast cancer that required a single mastectomy. Her mother was diagnosed at age 59, undergoing a lumpectomy and radiation treatment. Bruna opted for a bilateral mastectomy with reconstruction. “With my family history, along with my own personal history, I knew I wanted to remove as much risk as possible.” Her husband, Chris, has been her rock. “He literally has done everything for us,” Bruna says. “I could not have recovered the way I did without him.” ey’ve been married 18 years. ey have two sons: Joey, 14, and Luke, 11. Bruna derived comfort from nurse practitioner Tammy Root. “When you’re so scared, she’s exactly the type of person that you want in your corner.” It was Root who spoke with Bruna about the diagnosis on a Friday in June 2017. en, Monday morning, the Brunas met with breast surgeon Lisa Lai, MD, and Monday aernoon with plastic surgeon Prashant Upadhyaya, MD. ey liked the doctors and their surgical plans. “Dr. Lai and Dr. U. spent a lot of time with us, answering all of our questions and putting our fears to rest. It just clicked. You know how you just have a feeling?” Bruna’s surgery was June 28. It included the removal of lymph tissue to test whether the cancer had spread. It had not. “at’s the benefit of being screened,” Bruna says. “ey caught it so early.” Lai removed the breast tissue, and then Upadhyaya placed expanders in Bruna’s chest. e expanders are temporarily filled with air, and then replaced with saline aer some
spring 2018 l upstate.edu/cancer
Clockwise from left: Jordan Bruna, Prashant Upadhyaya, MD, nurse practitioner Tammy Root and Lisa Lai, MD. PHOTO BY ROBERT MESCAVAGE
healing. Bruna spent one night in the hospital before going home. Upadhyaya performed the second stage of reconstruction surgery in August. Bruna saw a genetic counselor through the Breast Cancer High Risk Program and discovered that she carries a gene variation that puts her at a higher risk for breast cancer and pancreatic cancer. She now sees a gastroenterologist who monitors her pancreas. Even though her breasts were removed, Bruna has a low risk that breast cancer could recur. So, she sees Lai every six months. “I’m very fortunate that I have a lot of great doctors. Our experience at Upstate throughout all of this has been incredible.” ●
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Helping a patient navigate through cancer’s challenges
SHARING EXPERTISE
Palliative care team helps Sandra Floyd reach the treatment goals she set for herself BY JIM HOWE
“THERE ARE A LOT OF UPS AND DOWNS when you’ve got cancer, a lot of wind in your sails, then the wind stops,” says Sandra Floyd as she describes living with cancer. Floyd, 68, lives in Georgetown, Madison County, and receives outpatient palliative care at the Upstate Cancer Center as part of her treatment for adenocarcinoma of the gallbladder. In many ways, she exemplifies what palliative care is designed to achieve as she deals with her disease: • Figuring out what she wants to accomplish at this stage of her life, then setting goals on how to get there. • Deciding to live with cancer without letting it define her. • Working with her medical team to decide which treatments are best for her and how to maintain the best possible quality of life while dealing with her disease, pain and side effects. Floyd, who runs the Fabius post office, could have retired six years ago but chose to keep working because “working gives you purpose. I usually enjoy my job, and I have a fantastic crew that works with me. If it hadn’t had been for them when I was first diagnosed, I probably wouldn’t have been able to maintain my job,” she noted. “I lost a lot of weight initially, but other than just being tired and a couple of episodes of pain, it’s under control. I really don’t have much pain at all anymore,” she said. When Floyd first came to the cancer center, in the fall of 2015, it was barely two months aer finding out that she had incurable cancer and being told she had, at most, a year to live. Gallbladder cancer is rare and hard to detect early. In her case, gastrointestinal pain was the first hint of a cancer that had already spread to her lungs and lymph nodes and advanced to its most serious stage, IV B. Since then, she has tried chemotherapy and immunotherapy, with limited success, and is currently taking a drug being tested for new uses in the MATCH trials. (See box, page 9.) at drug, Kadcyla, is used to fight breast cancer but is being tested on other cancers, and genetic testing of Floyd’s tumor suggested she could benefit. Floyd developed a low platelet count as a side effect of the drug. is endangered her blood’s clotting ability and forced her to withdraw from the trial. She was able to keep taking the drug at the cancer center,
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Upstate oncologist Stephen Graziano, MD, talks with his patient, Sandra Floyd. PHOTOS BY JOHN BERRY
however, where she is getting more time between doses to allow her platelets to recover, says her medical oncologist, Stephen Graziano, MD, Upstate’s chief of adult hematology and oncology. e drug “delivers a toxin directly to tumor cells,” Graziano explained. “It’s greatly benefiting her.” “She’s pretty remarkable. We hope she keeps doing well for as long as possible,” Graziano said. “Our goals are control, remission, shrink it down and improve her quality of life, we’ve been able to do all those things for her.” He noted a trend to get palliative care involved right at the beginning for advanced cancer cases, to help the patient deal with pain, quality of life issues and decisions about treatment. Dealing with those issues is just what Linda Troia, a physician assistant on the cancer center’s palliative care team, has helped Floyd to do. “One of the things I respect about Sandy is that she is someone who had cancer, and from the beginning, her goal was for it not to define her. She is aware she has it, doesn’t deny it and takes care of it, but she tries to live the best quality of life. She has been able to continue a life pretty much like her pre-cancer life, and it hasn’t been an easy task. She really focuses on living,” Troia said. “Something that I believe helps people is having goals. To continue to work is meaningful to her. Having goals you continued on page 8
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Helping a patient navigate
SHARING EXPERTISE
continued from page 7
Molecular Analysis for Therapy CHoice MATCH TRIALS AND ‘PRECISION’ CANCER CARE
Floyd, left, with Linda Troia, a physician assistant in the palliative care service at the Upstate Cancer Center.
work toward gives people a sense of purpose, and that is important because for some people cancer strips away that purpose. When they don’t have confidence in looking toward the future, they start to get stuck, depressed and lose their sense of purpose. “e goal helps to keep you motivated but reminds you of who you are and who you were before the cancer and, what makes you hold on,” Troia said. Floyd gets emotional support as well as medical care from Troia. “Linda has given me pep talks every time I come in, she does my pain meds and some of the other meds for me, and she is basically just a shoulder to lean on. It’s been really good,” Floyd said. ●
e National Cancer Institute sponsors tests of cancer treatments that analyze a patient’s tumor and take direct aim at certain genetic changes. If patients have a tumor with the genetic changes that match a drug being tested, they may be eligible to take part in a trial. is is a type of “precision” medicine, meaning it is tailored to the specific patient. While precision cancer treatments are progressing rapidly, they not yet routine nor available in all cases. ese trials are for patients with rare cancers or advanced cancers who have gone through standard treatments. e name MATCH stands for Molecular Analysis for erapy Choice. SOURCE: NATIONAL CANCER INSTITUTE
ADVICE FOR THOSE IN THE SAME BOAT
What would Sandra Floyd, who has outlived her original survival estimate by nearly two years, tell someone who has gallbladder cancer? “Don’t believe everything you read about it. It’s not an immediate death sentence. You just have to make up your mind to take care of yourself, don’t dwell in the negative as much as the positive, and just keep going,” she said. “I would also tell people to check for any drug trial out there.” Sandra Floyd
Experts on many cancer topics
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CANCER CARE
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SHARING EXPERTISE
A new option
Katsuhiro Kobayashi, MD, reviews images of the patient’s liver prior to the microwave ablation procedure. PHOTOS BY WILLIAM MUELLER
Technique heats the body’s water molecules to destroy cancer cells BY AMBER SMITH
OPTIONS ARE IMPORTANT when you have cancer of the liver.
which contain a high percentage of water, such as the liver and kidneys. It can also be used on bone lesions.
Vascular and interventional radiologists at Upstate now offer microwave ablation, a technique that uses heat to destroy cancer cells. e minimally invasive procedure can be an alternative to surgery. It may be used in addition to chemotherapy or radiation therapy.
Here’s how it works:
Katsuhiro Kobayashi, MD, says the Ethicon NeuWave equipment was purchased thanks to a grant from the Upstate Foundation. He appreciates that it can be used to ablate lesions — abnormalities — in a variety of shapes and sizes, and he finds it more precise than radiofrequency ablation, another method of destroying cancer with heat. Microwave ablation is an option for cancers in organs
e patient is sedated or anesthetized during the procedures so he or she is not bothered by the burning sensation. Kobayashi inserts a probe through the skin and into the tumor, periodically consulting medical images to make sure his trajectory is correct. Once the probe is in place, images confirm that it is in precisely the best location. Depending on the shape of the tumor, the tip of the probe emits either a circular or elongated sphere of microwaves, whose widths are controlled by the amount of time the machine is activated. When microwaves force them to continued on page 11
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SHARING EXPERTISE
Kobayashi inserts the 15 gauge probe into the patient’s liver. The microwave ablation, which disintegrates the tumor, lasts less than seven minutes. In the foreground is the Ethicon NeuWave equipment, which is loaded with images of the patient’s liver and surrounding organs.
A new option
continued from page 10
oscillate — move back and forth — water molecules within the tissue create heat, which disintegrates the cancer cells. ose dead cells are gradually replaced by scar tissue that shrinks over time. Microwaves are not impeded by blood vessels, and their heat dissipates much less than it does from radiofrequency waves. It’s generally quicker and more accurate. e ablation takes a few minutes. Aerward, Kobayashi examines three-dimensional images that look like ink drawings to see the area of destruction. “I think we got it all,” he says. To guard against any remaining cancer cells spreading along the probe track as the doctor retracts the probe, the machine cauterizes the area on the way out.
An illustration shows the tip of the probe and the microwaves it generates. COURTESY OF ETHICON
He says microwave ablation is a good option for many patients, especially those who might have difficulty with traditional surgery. Reach Vascular and Interventional Radiology by calling 315-464-5189. ●
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SHARING EXPERTISE
5 reasons you need a team of experts for esophageal or gastric cancer
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Cancers that arise in the stomach or along the tube that goes from the mouth to the stomach are sometimes difficult to distinguish. Both esophageal and gastric cancers usually begin in the cells that line the upper gastrointestinal tract, and they can produce some of the same symptoms: declining appetite, belly pain, trouble swallowing or a feeling of fullness aer eating a small meal.
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Distinguishing between esophageal and gastric cancer is important because the treatments of these cancers differ. Treatment for esophageal and gastric cancers can be highly complex and highly variable. Many of these cancers are advanced by the time they are discovered. ey tend to spread to the liver and the lungs. Because of where esophageal and gastric cancers are located, surgery may require approaches from the chest and from the abdomen. Having doctors who specialize in each area as part of the care team means they draw on one another’s expertise.
Not all medical centers have the expertise and equipment to manage cancers of the stomach and esophagus. Upstate does. A new patient at Upstate’s gastric and esophageal cancer program typically undergoes an endoscopic procedure or laparoscopic surgery to locate and “stage” his or her tumor. is is the process of confirming the location of the tumor and determining the severity of the cancer. “We’re looking for how are we going to be able to remove this tumor and, more importantly, how are we going to be able to put things together again once it’s out?” explains Jason Wallen, MD, the chief of thoracic surgery, who co-directs the gastric and esophageal cancer program with Ajay Jain, MD, the chief of surgical oncology. While the surgeons work closely together, Wallen or another chest surgeon usually cares for the patients with esophageal cancer. Jain or one of his abdominal 12
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surgery partners usually handles those with stomach cancer. Chest and abdominal surgeons collaborate with medical oncologists, pathologists, radiation oncologists, radiologists, gastroenterologists and nurse navigators who make up a care team for patients with gastric or esophageal cancers. Each patient’s case is discussed among the team. In a majority of cases, the team members end up agreeing on a recommendation. But not always. “When you have different specialists around the table, and something comes up that no one is sure about, it ultimately always leads to better care for our patients,” Wallen says. He related one situation in which the team could not agree, so specimens from the patient were sent to the National Cancer Institute for additional analysis, and further review by the Upstate team. e team might recommend surgery, but maybe not if tests reveal microscopic disease in the abdomen, or if distant lymph nodes are involved. Surgery might come later. Wallen explains: “One of the reasons we do chemotherapy and sometimes even radiation up front is that it’s so likely these cancers have spread beyond what we see at the point of diagnosis that we really need to take care of that disease that has spread beyond the initial area of the tumor. “at’s what is really dangerous. People don’t die from cancers in their stomach or esophagus. ey die from the cancers that have spread to other parts of their body. So that becomes the treatment priority.” Jain says that surgery might be effective if a tumor has grown into surrounding tissue, but shrinking the tumor first may give the patient a better outcome. It depends on many factors. “ese distinctions can be subtle, as to whether you should do chemotherapy first or surgery first,” he says. “You really do need an experienced group of people putting their heads together to come up with an individualized plan.” Patients interested in Upstate’s gastric and esophageal cancer program can call 315-464-HOPE (4673.) ●
Jason Wallen, MD
Ajay Jain, MD upstate.edu/cancer l spring 2018
SEARCHING FOR CURES
Complete & complex More cancer patients benefit from molecular diagnostics continued from back cover
Robert Corona, DO
“UPSTATE PROVIDES ACCESS to the most advanced testing and therapeutic options,” Robert Corona, DO, told community leaders in a presentation recently. As leader of the medical center’s pathology department, he is raising the quality of cancer diagnostics for patients in the region to be on par with leading national institutions.
How? rough the recruitment of experts in clinical genetics and molecular diagnostics:
Steven Sperber, PhD
STEVEN SPERBER, PHD, is a clinical molecular geneticist who is bringing to the molecular pathology laboratory at Upstate “next generation sequencing.” Instead of examining a single gene, next generation sequencing creates a molecular profile of dozens, hundreds or even thousands of genes at once. It’s faster, easier and provides more complete analysis, Sperber explains, and the results can be complex.
He completed his clinical molecular genetics fellowships at the National Human Genome Research Institute in 2009 and worked in diagnostics testing laboratories and academia before joining Upstate last fall. His doctorate in cellular and molecular medicine is from the University of Ottawa. “Our big goal is to get a profile of a tumor, whether it’s a solid tumor, a lymphoma or a blood-related cancer,” Sperber says. e job then becomes finding and interpreting the mutations, particularly those for which clinical therapies are available. A growing number of medications with companion diagnostics are receiving approval from the Food and Drug Administration. Patients have to be tested before they can receive the drug. e first of these so-called precision treatments was approved in 1998. e drug, Herceptin, treats an aggressive form of breast cancer; its companion diagnostic looks for a particular protein or spring 2018 l upstate.edu/cancer
extra copies of a particular gene in a patient’s tumor to predict whether Herceptin will be effective. en there are the “tissue agnostic” therapies, the first of which — Keytruda — was approved in May 2017. It’s meant to treat solid tumors bearing a specific genetic marker, regardless of where they arise. JEFFREY ROSS, MD, is a molecular pathologist. He leads the Upstate Cancer Center’s monthly “molecular tumor board” meetings. at’s when a team of cancer doctors gathers to discuss treatment options for patients whose DNA has been sequenced. Ross describes the mutations and how they may impact the selection of treatment for each individual. Together, the team comes up with a precision treatment recommendation. “Instead of the one-size-fits-all approach and the sequential use of drugs based on the performance of the previous regimen, now we want to give each patient a Jeffrey Ross, MD custom-designed treatment that’s essentially driven by the genomic makeup of their cancer,” explains Ross. He went to medical school at the University of Buffalo and is board certified in anatomic pathology and clinical pathology. He joined Upstate this year. Most patients whose cases are discussed at the molecular tumor board have advanced cancers that have either spread or been treated and relapsed. Precision treatment —also sometimes called personalized medicine — can prolong their lives. Ross says pharmaceutical companies are excited about making these drugs because “the patient oen transitions from what is an acute and possibly fatal disease into a chronic and survivable disease. e drug becomes a maintenance drug, meaning the patient never goes off treatment but lives months or years or tens of years while still on the drug — which makes that, of course, very financially attractive to drug makers.” Continued on page 14
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New terms for the new era BIOINFORMATICS — the science of collecting and analyzing genetic information or other complex biological data. GENOME — the complete set of genes or genetic material in a cell or organism. GENOMIC DRIVER — what it is about a gene that drives the recurrence of a genomic aberration. GENETIC MUTATION — a permanent alteration in a genomic sequence. IMMUNOTHERAPY — treatment that boosts or suppresses the body’s immune response. NEXT GENERATION SEQUENCING — technology that revolutionizes biological sciences, thanks to engineering and computing power, and allows for analysis of a whole genome rather than a single gene. PAN-CANCER — an ongoing project that analyzes what’s common and what’s different across a variety of tumor types. PERSONALIZED MEDICINE — customized treatment made possible with genetic sequencing. PHENOTYPE — observable characteristics that occur because of the interaction of an individual’s genotype (or genetic identity) with the environment. TISSUE-AGNOSTIC — refers to a drug designed to work on cancers with a specific mutation, rather than cancers that originate in a particular area of the body.
Complete & complex
continued from page 12
e most direct application of sequencing DNA from cancer cells applies to anti-cancer drugs, but Ross says radiation therapy is sometimes also impacted. “Radiation can now be given to increase the number of mutations in the patient’s cancer, which will then help immunize the patient against their own cancer cells. And then, when the immunotherapy drugs are given, the patient starts to reject their own cancer like it was a transplanted organ from an unrelated donor.” An exciting time
Many of the cancer treatments available today were not even thought of before 2003, when the human genome was sequenced. Doctors and caregivers typically consult laboratory geneticists like Sperber or molecular pathologists like Ross before ordering molecular tests. “e field is changing so fast, and it’s complicated,” Sperber
says, “and different laboratories offer different tests.” He says it’s an exciting time to be a scientist. Researchers are trying to develop ultrasensitive methods of detecting genetic mutations from blood samples long before a patient exhibits signs or symptoms. is could help diagnose cancers like ovarian, lung and pancreatic cancer, which typically are not discovered until they are advanced. “You could literally see it coming years ahead, or at least months ahead,” Sperber says of the potential for using molecular testing to predict cancers at the earliest stages in the future. ● FINDING THE RIGHT DRUG FOR THE PATIENT
Researchers share their work related to the clinical application of genomic science in e Pharmacogenomics Journal, an international peer-reviewed quarterly publication whose founding editor-inchief is Julio Licinio, MD, PhD, dean of Upstate’s College of Medicine. e journal was launched in 2001.
LOOKING FOR A CAREER?
Clinical molecular geneticist Steven Sperber, PhD, says a shortage exists of people with training in molecular diagnostics and molecular technology. Upstate offers training in clinical laboratory sciences, including bachelor’s degrees in medical biotechnology and medical technology, and master’s degrees in medical technology. Learn more at www.upstate.edu/chp
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Julio Licinio, MD, PhD
Licinio, a professor of psychiatry, pharmacology and medicine, has expertise in pharmacogenomics, the science of how a person’s genetic makeup affects how his or her body responds to drugs. ● upstate.edu/cancer l spring 2018
SEARCHING FOR CURES
Capitalizing on cancer’s sweet tooth
How a special diet may enhance radiation treatment for glioblastoma BY AMBER SMITH
CAN EATING A HIGH-FAT, LOW-CARB DIET help people undergoing radiation treatment for fast-growing cancerous brain tumors? e chief of neurosurgery and a fourth-year medical student who is going into radiation oncology have teamed up to study whether a ketogenic diet during radiation therapy can improve the prognosis for patients with glioblastoma, an aggressive brain cancer. A diet high in fat and low in sugar and carbohydrates, which break down into sugar, is meant to force healthy brain cells to get their nutrition from fat instead of sugar. Cancer cells rely on sugar in order to keep dividing and spreading, which makes them resistant to radiation treatment. ey do not appear to be able to substitute fat for a nutritional source the way healthy cells can. “e idea behind dietary therapy is to target this need for nutrition and also to make radiation treatment more effective,” explains Larry Chin, MD, the medical director of Upstate’s neuro oncology program. Other forms of therapy are aimed at killing the tumor in some way, using chemicals or radiation. “e idea with dietary maneuvers is, you’re trying to starve the tumors and also at the same time make them more vulnerable to radiation therapy. It’s a different way of getting at the tumor cell.” A ketogenic diet does not replace treatment. “Because this is a different mechanism of attacking the tumor, hopefully the diet will be synergistic so that it will add to the effectiveness of the traditional treatments — and maybe make them more effective.”
WHAT IS A KETOGENIC DIET?
A ketogenic diet is an extreme low-carbohydrate diet. It includes excessive amounts of fat and limited protein and carbohydrates – basically, lots of vegetables and bacon. Food that are avoided include those with added sugar and those that break down into simple sugars, including breads, starches, cereals and pastas. Chin is the mentor for Hans Kim, a fourth-year medical student who is working with the Upstate Foundation to seek donations to pay for a study. (Learn more at www.upstatefoundation.org/diet-for-cancer-patients) Money would be used to pay for materials for patients with glioblastoma who agree to participate. ey would need: 1. an electronic scale, to make sure they don’t eat more than 20 grams of carbohydrates per day; 2. a ketone breath taker, to measure their ketosis — the process of burning fat for fuel — during the radiation treatment period; and 3. commercially available ketogenic shakes to assist in following the diet. Kim developed an interest in the possible value of ketogenic diets beginning with his undergraduate work at the University of Pennsylvania and the University of Iowa. He was inspired by the pioneering work in cancer metabolism led by cell biologist Craig ompson, MD, now president of the Memorial Sloan Kettering Cancer Center. Also, during a summer spent in the laboratory of Douglas Spitz, PhD, at the University of Iowa, Kim decided continued on page 16
spring 2018 l upstate.edu/cancer
CANCER CARE
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SEARCHING FOR CURES
Capitalizing on cancer’s sweet tooth
continued from page 15
to pursue radiation oncology aer learning that radiation therapy is the key to tackling the metabolic aspects of cancer. Later, he helped his mother follow a ketogenic diet during her battle with advanced head and neck cancer. “It’s a very hard diet to comply with,” Kim acknowledges. Also, since human bodies are used to a carbohydrate-rich diet, switching to a ketogenic diet may prompt flulike symptoms at first. He says it’s safe, if followed correctly. “You first need to know how much carbohydrates you intake every day, and then gradually reduce the carb intake so that your body has time to adapt.” Studying the effect of ketogenic diets on patients in treatment for glioblastoma, Kim says, “may contribute to fundamentally changing the way we treat cancer patients.”
Larry Chin, MD, left, chief of neurosurgery, and Hans Kim, medical student, in the Upstate Cancer Center PHOTO BY RICHARD WHELSKY
He says the idea can be expanded to other types of cancer, too. Research has shown that when a ketogenic diet is combined with radiation in laboratory mice that have specific types of tumors, their survival drastically improves. “Imagine if we can prove that in humans,” Kim says. “Cancer patients will have the power to change their own treatment outcome by changing their diet during radiation treatment.”●
WHAT IS GLIOBLASTOMA?
Glioblastoma is a fast-growing cancerous brain tumor that typically is diagnosed in older adults. It spreads throughout the brain, making it impossible to remove entirely with surgery. Treatment usually includes radiation and/or chemotherapy. e cause of these tumors is unknown.
Opportunities. Consider Upstate. Our colleges include Medicine, Nursing, Health Professions and Graduate Studies. Join us at a prospective student open house. www.upstate.edu/students
Education
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Health Care .
Research
upstate.edu/cancer l spring 2018
The talcum powder – ovarian cancer connection
LIVING WITH CANCER
BY AMBER SMITH
TALCUM POWDER MAY INCREASE by about 20 percent a woman’s risk for developing ovarian cancer. Chemicals in the powder, which some women use in the genital area to promote dryness, can ascend through the vagina into the genital tract and Fallopian tubes, providing a toxic exposure over time, says Upstate gynecologist Jennifer Makin, MD.
Jennifer Makin, MD
e International Agency for Research on Cancer classifies talcum powder as a possible carcinogen, she says, adding that case control studies have shown an association between talc and ovarian cancer. However, Makin notes, association has not been shown in any prospective studies, so there is no proof of causation.
powder because it can alter vaginal pH, or acidity, levels and prompt the growth of harmful bacteria. “Using powder in the genital area is not recommended,” she says. “If moisture or odor is a problem, we can investigate those possible causes.” Talc is a mineral made up of magnesium, silicon and oxygen. In its natural form, talc contains asbestos, a substance known to cause cancers in and around the lungs when inhaled, according to the American Cancer Society. Since the 1970s, household talcum products have been free of asbestos. ●
Connecting pediatric cancer families Makin advises her patients not to use talcum powder for that reason. She also discourages the use of cornstarch
THE UPSTATE CANCER Center and the Upstate Golisano Children’s Hospital provide a connection group for pediatric cancer families. It’s called H.O.P.E., Helping Oncology Patients and Parents Engage.
Kaushal Nanavati, MD, medical director of integrative therapy, led the first group session, discussing strategies for stress management. e second event will include a paint night for adults, cras for kids and a pizza party for teens. Child care will be available. To learn more about H.O.P.E., contact Kristen omas at 315-4647227 or omaKri@upstate.edu ●
Kristen Thomas, RN
spring 2018 l upstate.edu/cancer
The Waters Center for Children’s Cancer and Blood Disorders at the Upstate Cancer Center.
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LIVING WITH CANCER IN THE KNOW
Chicken and White Bean Soup YOU CAN HAVE “homemade” chicken soup quickly with the help of a store-bought rotisserie chicken. e mildly seasoned plain or lemon pepper chickens are recommended. is soup uses protein-packed beans instead of noodles, but you’re welcome to substitute ½ cup of egg noodles for the beans if you seek a classic chicken noodle soup. Also, you can boost the nutritional value by adding a few handfuls of baby spinach right before serving. is recipe serves 6 to 8.
Preparation 1. Remove wings from chicken and reserve. Remove skin from breast and discard. Shred the meat from the breast and break off breastbones. 2. In a stockpot over medium heat, add oil. Sauté the carrots, celery, onion, chicken wings, and breastbones for 8 to 10 minutes, or until vegetables soen. 3. Add water and chicken broth and bring to a boil, stirring to combine. Reduce the heat, cover and simmer for 15 to 20 minutes. Add beans and chicken meat and cook for 5 minutes. If too thick, add additional broth or water. Discard bones and wings before serving. Season with salt and pepper. SOURCE: AMERICAN CANCER SOCIETY’S “THE GREAT AMERICAN EAT-RIGHT COOKBOOK”
Ingredients 1 rotisserie chicken breast section, or 3 cups chopped white chicken meat 1 tablespoon canola oil 3 carrots, sliced 2 celery stalks, sliced 1 onion, chopped 2 cups water 6 cups reduced–sodium chicken broth 1 15-ounce can Great Northern beans, rinsed and drained salt and freshly ground black pepper
Nutritional information per serving: 235 calories 5 grams total fat 60 milligrams cholesterol 675 milligrams sodium 17 grams total carbohydrate 5 grams dietary fiber 5 grams sugars 28 grams protein
As the longest established bariatric program in Central New York, Upstate has a proven track record of successful patient outcomes. If you are considering bariatric (weight loss) surgery, come learn more from our experts about how it can improve your overall health.
TO REGISTER FOR A FREE UPCOMING INFO SESSION, VISIT WWW.UPSTATE.EDU/BARIATRICS OR CALL (315) 492-5036. Information sessions are held at Upstate University Hospital’s Community Campus, 4900 Broad Road, Syracuse. (Formerly Community General Hospital)
FREE PARKING IS AVAILABLE IN THE HOSPITAL PARKING GARAGE.
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upstate.edu/cancer l spring 2018
MAKING A DIFFERENCE
Tutus and butterfly wings were part of the uniform for this YMCA team.
William Baugh, center, and his family volunteer at Paige’s Butterfly Run in memory of their daughter, Arie, who died of kidney cancer at 22 months.
20+ years of helping kids and families Runners of all ages participate in Paige’s Butterfly Run to support children with cancer.
PHOTOS BY SUSAN KEETER
Jillian Tandle, Samantha Prayne and Eden Prayne travelled from Seneca Falls to run in Paige’s Butterfly Run.
RUNNERS AND THEIR SUPPORTERS at Paige’s Butterfly Run have raised more than $2 million over the last 20 years to support cancer research and cancer care at the Upstate Golisano Children’s Hospital.
Chris Arnold and Ellen Yeomans started the run in honor of their daughter Paige, who died from leukemia in 1994. Over the years, the run has become the centerpiece of a year-round fundraising effort coordinated by the Paige’s board. Other events include a Pedaling for Paige event, a Clams for Cures clambake and a Pajamarama, in which students and teachers make donations and in return get to wear pajamas to school on a certain day.
Paige Arnold
Last year’s 20th anniversary run brought in $210,000, which was presented to the children’s hospital in the form of a check. “e contributions from Paige’s Run have a direct impact on the families receiving care at Upstate but also support research in the hope of ending childhood cancer for all,” says Toni Gary, director of community relations for e Upstate Foundation. Money from Paige’s helps pay for a variety of services, including sand therapy materials; a “family fun” fund that child life specialists tap to help pay for birthday and holiday celebrations; equipment for hemophilia patients; backpack comfort kits (with toiletries and gi cards for food and gas) for newly diagnosed patients; assistance for families who have financial difficulties as a result of their child’s illness; burial costs and grief counseling; neuropsychological testing for children with cancer; education for local and outlying doctors and other medical providers; and research projects related to childhood cancer. ●
spring 2018 l upstate.edu/cancer
REGISTER FOR THE RUN
Paige’s Butterfly Run takes place June 2 this year in downtown Syracuse, during the annual Taste of Syracuse festival. e event includes a 5K race, a 3K fun run/walk and a 40-foot Caterpillar Crawl for children 5 and under. Register online at www.pbrun.org
CANCER CARE
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750 East Adams Street l Syracuse, NY 13210
UPClose
Complete & complex More cancer patients benefit from molecular diagnostics BY AMBER SMITH
WE ARE USED TO DIFFERENTIATING CANCERS by where they were discovered: breast cancer, lung cancer, colon cancer.
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Cancer doctors and scientists today are starting to label cancers based on their genetic makeup — and that’s only the beginning of a new era in cancer treatment happening in Syracuse. Already, some Upstate patients take drugs that fight cancer not by killing cancer cells but by allowing their immune systems to put the brakes on cancer’s growth. Some patients undergo simple blood tests known as liquid biopsies to check for traces of cancer DNA. Some have tissue specimens analyzed by clinical geneticists. Some receive treatment recommendations from cancer doctors who confer with molecular pathologists about which drugs are most likely to work best. continued on page 13
This image, made with fluorescent probes, shows amplification of HER2, a gene that can play a role in breast cancer. FROM THE LAB OF STEVEN SPERBER, PHD