44 minute read
WellNow Urgent Care Offers Allergy Testing and Treatment
Randi Minetor
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When Jeanne Lomas, DO, was the associate program director for the University of Rochester’s allergy and immunology fellowship program, she discovered a disturbing trend that would eventually limit services to patients. “I attended a national meeting for allergy fellowship leadership,” she said. “Many programs had empty slots— which is crazy, because subspecialty fellowships are highly competitive. Allergists are retiring faster than new ones are being trained. Many areas of the country just cannot recruit allergists.”
Meanwhile, more people have allergies than ever in recorded history. The American Academy of Allergy, Asthma and Immunology (AAAAI) reports that the number of people with allergic diseases has risen steadily in the industrialized world for more than 50 years. At least 40 percent of schoolchildren worldwide have a sensitivity to
one or more common allergens, and about 13 percent of people in the US over the age of 18 have sinusitis, an allergyaggravated chronic condition.
The Asthma and Allergy Foundation of America (AAFA) and the American College of Allergy, Asthma and immunology (ACAAI) tell us that allergies are the sixth leading cause of chronic illness in America, with 19.2 million adults and 5.2 million children diagnosed with allergic rhinitis (hay fever) alone. A remarkable 9.2 million American children had skin allergies (rash or hives) in 2018, with Black children dominating these numbers.
As high as the numbers are for respiratory and skin allergies, the impact of food allergies is even higher. About 32 million people in the US are allergic to one of the eight foods that cause most reactions: eggs, fish, milk, peanuts, shellfish, soy, tree nuts, and wheat. Anaphylaxis, the most severe and life-threating reaction to a specific food, produces 30,000 emergency room visits annually, according to FoodSafety.gov.
Jeanne Lomas, DO
“The numbers of patients with access to treatment is decreasing, while the prevalence of allergic diseases is increasing,” said Dr. Lomas.
She saw an opportunity to do something about this when she joined the staff of WellNow Urgent Care, taking the role of Director of Allergy and Immunology Services. Here she developed a program to provide quality allergy services to patients, expanding their access to quality care. Patients come to a WellNow Urgent Care clinic for allergy testing and treatment—but they do not need to be in an emergent situation to visit this clinic. “We’re set up as a pilot program in our Clarence facility with a separate clinic area from the urgent care so people aren’t coming into the urgent care side,” Dr. Lomas explained. Patients can schedule a clinic appointment online and come in for a full allergy workup, including environmental skin testing. Once their allergies have been defined, they can go to any WellNow clinic for allergy shots or other therapies. “Allergy shots are meant to desensitize you to allergens like cat dander and pollens,” she said. “You build up a tolerance to these allergens, so they don’t give you the same symptoms when you’re exposed. It works really, really well—we can potentially cure people of their environmental allergies—and it’s safe, even for young children and most pregnant women!”
The barrier to treatment, however, is that patients who are
seen by an allergist in private practice or a hospital-based clinic can only receive allergy shots when the clinic is open. “So for people who are in school or working, it’s hard,” she said.
WellNow clinics are open during the evenings and on weekends. “Typically, allergy shots are given once per week for the first few months,” she said. “It’s a big time commitment. WellNow bridges this gap with more flexible hours, so we can offer this service to more people who would otherwise not be able to commit to the therapy.”
Dr. Lomas noted that patients who could not make this kind of commitment to their own wellness—whether because of work schedules or family obligations—often try to minimize their discomfort. “Sometimes people think their allergy symptoms are not that big a problem,” she said. “But I see all of the time that we can relate their allergies to other things—sinus infections, or asthma attacks, even poor sleep. Their symptoms may be worse than they realize. The allergies are a chronic disease that they’ve been fighting their whole lives. When you offer them a treatment that works, it changes everything.”
The new program began in July 2021, and it already sees a full roster of patients on clinic days. “We are hiring and have more providers starting, so that we can meet the demand,” she said.
WellNow Allergy currently offers full allergy evaluations including environmental skin testing, spirometry (pulmonary function testing), and patch testing, as well as blood draws. Dr. Lomas is planning on expanding services to food and venom skin testing within the next 6 months. One of the most common misdiagnoses is a penicillin allergy, Dr. Lomas noted. “About 95 percent or more of patients who report a history of penicillin allergy can actually tolerate the drug,” she said. “There are many studies showing that if you are listed as penicillin-allergic, you are more likely to be prescribed alternative antibiotics, which are most costly and have more side effects. So we can evaluate for that and help these patients take it off their allergy list.”
A graduate of the University at Buffalo and Lake Erie College of Osteopathic Medicine, Dr. Lomas served as chief resident in pediatrics at the University of Rochester Medical Center (URMC), and went on to complete a fellowship at URMC in Allergy & Immunology. She then served on faculty as an assistant professor of Allergy and Immunology at URMC for nearly six years before arriving at WellNow.
“I completed a pediatrics residency prior to allergy & immunology training—we treat little kids to adults and elderly patients, and the span of ages is really attractive to me,” she said. “There are very few specialties in medicine where you can provide as much relief for patients as you can by treating their allergies. I say to my patients, ‘I’m so excited for you because you are going to feel so much better.’”
Relieving and curing allergies has the added benefit of improving patients’ quality of life for the long term, she added. “Patients are super-appreciative. It’s a very rewarding field.”
Randi Minetor is the author of Medical Tests in Context: Innovations and Insights (Greenwood, 2019) and is a freelance journalist based in Rochester.
Responding to Online Reviews and Social Media Posts
Authored by Martin Kaiser, a MLMIC Risk Management Consultant, and Edward Krause, a Claims Assistant Vice President with MLMIC
It goes without saying that social media is a huge part of our lives today. A Pew Research study reported that 69% of adults in America use social media on a regular basis, including 27% of people over age 55. Many “baby boomers” rely on the internet to obtain their healthcare information, including provider reviews.
Most hospitals use social media for their marketing efforts, as well as customer outreach and engagement. It is also estimated that over 90% of healthcare providers use social media for personal activities and over 65% of providers use this medium for professional reasons, including providing organizational news and details of services provided, offering patient education, and detailing the availability of community events and wellness programs.
A significant amount of interaction by the public on social media sites includes individuals looking for healthcare advice and recommendations for care, as well as information from those who have had personal experience with specific providers. These social media platforms include such familiar names as Facebook, Twitter, Angi, and Yelp, as well as healthcare-specific sites such as WebMD, VITALS, and RATEMD, with new sites seemingly appearing every day.
It should be noted that while 90% of all online reviews about the patient experience and provider care are positive, some negative reviews will be posted. What follows will help to identify and address negative comments appearing on social media websites.
Problematic Aspects of the Use of Social Media by Patients
Unfortunately, when patients and/or their families use social media platforms to voice negative comments about the provision of their healthcare, there may be problems associated with their posted messages. These may include the quality and credibility of information posted by the individual; the posting of information that may be misconstrued or taken out of context by those present on the social media site; and even the posting of inappropriate or discriminatory personal comments about you or your staff. Such posts may become a distraction to those providers who frequently visit social media sites, or even the comment section of their own website, to see what is being written about them and their practice. This “web surfing” may result in poor care or medical error.
Reacting to negative comments that are posted on a social media site may present several problems for the provider. First, a direct response via the social media platform to the author of the negative comment may confirm that the individual is a patient of the provider, thus breaching the patient’s privacy. Further, a comment in response to a negative post may be perceived as unprofessional by the patient or their family, or to prospective patients who are vetting the provider to see if they wish to become his or her patient.
It should always be remembered that the internet is truly “worldwide,” and it must be understood that any advice or information that you post on the social media platform may be read by out-of-state patients, potentially raising licensing issues if it appears that medical advice was provided in a state where the provider is not licensed.
Addressing Negative Online Reviews
Unfortunately, you cannot prevent negative posts from being written about you or your practice, and it is often difficult to have them taken down. The best practice is to continue to provide optimum care to your patients, and to respond in an appropriate manner. Most importantly, resist the urge to ignore the negative review or to retaliate. Do not engage in online arguments with the individual, as this is a direct violation of your professional boundaries. The negative concern expressed should be reviewed by you and your staff to verify if it is accurate, and then corrective actions should be taken, if applicable.
If the author of the post can be determined, you may contact that person offline to address the stated concerns. When contact is made, be sure to document the entire conversation in the patient’s medical record. A patient portal may be employed to facilitate the proper documentation of this conversation. If it becomes apparent that there is some basis for the negative comment and corrective action has taken place, the patient should be contacted and thanked for bringing their concern to the practice’s attention. You may even let them know how their concern helped the practice improve. This may even improve the patient’s image of the practice.
In the event the posted concern pertains to an untoward outcome, or if you suspect legal action is being threatened, contact the MLMIC Claims department as soon as possible. Always print and retain all patient social media posts, as patients may choose to delete their comments from the social media platform.
Risk Management Strategies for Negative Online Reviews
The development of a formal social media policy is the first step in instituting a plan to help guide you and your staff if a negative review about your practice is posted online. The following Items should be addressed in a practice’s social media plan: • Assign a staff member to review social media sites on a regular basis for posts about your practice, and to constantly address evolving social media and technology. If your practice includes separate locations, these reviews should be conducted for each location. • Designate a person to communicate on behalf of the practice. This person is often the risk or corporate compliance manager, practice administrator, or, in solo practices, the actual provider. • Reiterate to staff the need to maintain the same patient confidentiality online as they would in any other environment, as well as maintain appropriate boundaries in the physician-patient relationship.
Never “friend” a patient in an online setting. • If you feel you are being pressured into responding on a social media platform, limit your response to a standardized response such as one of the following: “According to state and privacy laws, we are precluded from commenting on patient treatment. However, we are always available to discuss concerns with our patients. Patients are welcome to contact us directly.” “In order to protect our patients’ privacy, all patient concerns and complaints are resolved directly by [name of practice] and not through social media.” “At [name of practice], we strive for the highest levels of patient satisfaction. However, we cannot discuss specific situations due to patient privacy regulations. We encourage those with questions or concerns to contact us directly at our office.” • All staff should be alerted to immediately report negative social media comments to practice leadership. • Link your social media policy to other organizational policies, such as an employment agreement. A confidentiality agreement should be signed by your staff members, and they should receive documented education in patient privacy and HIPAA. A well-intentioned social media post by a staff member may trigger HIPAA concerns.
Reprinted with permission from www.MLMIC.com. All Rights Reserved. No part may be reproduced or transmitted in any form or by any means, electronic, photocopying, or otherwise, without the written permission of MLMIC.
Roswell Park Comprehensive Cancer Center and Oishei Children’s Hospital Launch First Edition City of Buffalo MONOPOLY to Benefit Pediatric Cancer Patients
100% of game sales support Roswell Park Oishei Children's Cancer and Blood Disorders Program
Roswell Park Comprehensive Cancer Center and John R. Oishei Children’s Hospital have launched the First Edition City of Buffalo MONOPOLY® game, officially licensed by Hasbro, to benefit the Roswell Park Oishei Children’s Cancer and Blood Disorders Program for pediatric cancer patients.
One hundred percent of the proceeds from the sale of the game will have long-term benefit to the program, helping ensure that children and their families facing childhood cancer and blood disorders can remain in Western New York to receive the very best care. “The funds raised through the sale of this game will specifically fund a critical position on our Roswell Park Oishei Children’s Cancer and Blood Disorders Program care team - a Bone Marrow Transplant Coordinator,” said Kara Kelly, MD, the Waldemar J. Kaminski Endowed Chair of Pediatrics at Roswell Park and Chair of the Roswell Park Oishei Children’s Cancer and Blood Disorders Program. “Our joint program has helped us to nearly triple the number of bone marrow transplants that we perform, allowing families facing a pediatric cancer diagnosis to stay right here in our community to receive care. Having a dedicated Bone Marrow Transplant Coordinator, funded by the sales of the City of Buffalo MONOPOLY game, will help to ensure that there is seamless support for the care delivered across both Roswell Park and Oishei Children’s Hospital.”
Each year, Hasbro selects a limited number of custom MONOPOLY games to produce, and this year Buffalo was on that short list. The First Edition City of Buffalo MONOPOLY game features iconic hometown brands and corporations across Buffalo, bringing to life an authentic snapshot of what makes this community so special.
The game can be purchased for $50 exclusively at participating Tops Friendly Markets locations while supplies last. “As part of our Neighbors Helping Neighbors philosophy, we have supported both the Roswell Park Comprehensive Cancer Center and Oishei Children’s Hospital programming for many years, but this is a unique and exciting fundraiser for both charities,” said John Persons, president and COO. “We truly believe in the work of both agencies as they align nicely with our philanthropic mission and we hope everyone enjoys this Western New York version of the game.”
Keeping Tabs on the Tax Changes
The tax code has been through a whirlwind these past few years. We’d forgive our readers if they have a hard time keeping it all straight.
To briefly recap, the changes started at the end of 2019 with the passage of the SECURE Act, which changed a number of rules relating to IRAs and retirement plans. Then, in early 2020 when the pandemic was beginning, various COVID-relief bills were put in place, such as the CARES Act, and the multitude of changes they brought. And most recently, there are the ambitious ideas being pursued by the Biden Administration and its Congressional allies. And all of that doesn’t even count President Trump’s signature Tax Cuts and Jobs Act of just a few years prior!
Financial planning best practices are continuing to evolve in today’s quickly shifting landscape. For those interested in peering around the corner, highlighted below are a few of the key proposals we have on our radar for the rest of 2021.
The Next Shoe to Drop
Months and months in the making, a $1 trillion infrastructure bill passed the Senate in early August. The most recent indications are that the House has agreed to vote on the bill in late September.
Rather than including any tax increases along with the spending, the bill makes use of several non-tax offsets. In addition, the $1 trillion number includes pre-authori-
zation for 5 years of typical transportation maintenance spending. This spending is not really ‘additional spending’, further bringing down the real size of the infrastructure thrust and lessening the political pressure to raise offsetting revenues.
Meanwhile, the House and Senate also approved a 2022 budget resolution that provides reconciliation instructions for a $3.5 trillion spending package. Reconciliation allows for budget-related bills to pass filibuster proof with only a simple majority, meaning that a larger spending bill could potentially pass later this year without any Republican support.
It’s possible for the full package to pass, but we think that is unlikely. With the Senate evenly divided 50-50, this route requires the Democrats to stay completely united. They literally would not be able to lose a single Senate vote. Such a razor thin majority means that we think compromise is likely on many of the key provisions of President Biden’s agenda. Additionally, due to limitations of the budget reconciliation process, bills must be ‘revenue neutral,’ meaning Congress cannot finance the package via the deficit. Paying for most, if not all, of the proposals will require a variety of tax increases, predominately impacting high income individuals and corporations.
The Art of Compromise
Due to the slim majorities, Democrats have already begun to compromise on a couple of President Biden’s initial tax proposals. Here is a summary of where things stand currently on key tax issues, as well as on a few items that seem to already be on hold:
Individual Taxes: Democrats have consistently stated their intention is to avoid raising taxes on families making less than $400,000. Current proposals remain for raising the top marginal income tax rate from 37% to 39.6%, which would apply to income over $452,700 for single and head of household filers and $509,300 for joint filers.
Corporate Taxes: There still appears to be a strong push to raise the corporate tax rate, which was previously lowered from 35% down to 21% in 2017 as part of the Tax Cuts and Jobs Act. Numbers have ranged between 25% to 28%, with the higher number remaining the preferred figure. The Democratic party has declared, however, that they will not raise taxes on small businesses (e.g., family farms).
Investment Taxes: Proposals remain intact to treat long-term capital gains and qualified dividends as ordinary income for taxpayers with taxable income above $1 million. If enacted, this would result in a top marginal capital gains tax rate of 43.4%, when including a new top marginal rate of 39.6% and the 3.8% net investment income tax.
Estate Taxes: This may seem like the most cut and dry of impacted areas, although nothing in trust and estate tax law is ever that simple. Nevertheless, current plans call for capital gains taxes at death on unrealized gains above $1 million for individual and $2 million for joint filers.
A Few Items on Hold: Original plans to apply the social security payroll tax on wages above $400,000, to restore the 2009 federal estate and gift tax levels ($3.5 million federal exemption and $1 million lifetime gift limit at a 45% maximum tax rate), and to place a cap itemized deductions for higher earners all appear to be on thin ice at the moment.
As always, we will continue to closely monitor the evolving situation in DC for potential impacts on your financial plan. As these plans come into greater focus, we may make recommendations on a proactive basis to help clients get in front of any potential issues that can impact specific planning goals. Please feel free to schedule a call with a Financial Consultant if you have any questions, and in the meantime, subscribe to our Financial Planning blog for updates on these issues and more.
Please consult with an attorney or a tax or financial advisor regarding your specific legal, tax, estate planning, or financial situation. The information in this article is not intended as legal or tax advice.
Is Remote Patient Monitoring Right for Your Practice?
Brigid M. Maloney, Esq.
In the past three years, the Centers for Medicare and Medicaid Services (CMS) significantly expanded reimbursement opportunities for physicians who properly utilize remote patient monitoring with qualifying patients. Remote patient monitoring, also referred to as remote physiologic monitoring, involves the use of digital technology to monitor and report medical data from patients with chronic and/or acute health conditions and electronically transmitting such information to healthcare providers for assessment. Common digital equipment used for remote patient monitoring include blood glucose monitors, digital weight scales, blood pressure monitors, and pulse oximeters.
Remote patient monitoring reimbursement is based on the premise that additional monitoring of patient health data, combined with increased communications with patients and adjustments to treatment plans based on such data will result in healthier patients, better clinical outcomes, and lower health care costs. A 2013 study published in JAMA demonstrates how remote patient monitoring has the potential to significantly increase blood pressure control. A 2020 study published in JAMA found that in a randomized clinical trial of 242 patients, a remote monitoring program resulted in a reduction in rehospitalizations of patients following hip and knee arthroplasty.
CMS will likely continue to refine the broad reimbursement policies that are presently in place as more data become available and the benefits and overall clinical effectiveness of specific devices and diseases are studied more closely.
In the meantime, physicians who are treating patients with chronic or acute conditions may elect to initiate remote patient monitoring for reimbursement using CPT codes 99453, 99454, 99457, 99458, and 99091, as follows: 99453 - Device set-up and training. This code reflects staff time that includes instructing a patient or caregiver about using one or more medical devices for remote monitoring. This code can only be billed once per device. Reimbursement in Upstate New York is approximately $19.00. 99454 - Daily collection and monitoring of patient physiological data. To qualify, data must be transmitted to the provider at least 16 or more days in each 30-day period. During the COVID public health emergency, the required number of monthly reporting days is reduced from 16 days to two days. Reimbursement in Upstate New York is approximately $60.00 per patient, per 30day period. 99457 – Treatment management, 20 minutes per month of review, including live, interactive communication with the patient, by a physician clinical staff member under the general supervision of the ordering physician. This code also includes time spent furnishing care management services. Reimbursement in Upstate New York is approximately $50.00 per patient, per calendar month. 99458 – Treatment management, additional 20 minutes or more beyond the 20 minutes provided under 99457 Reimbursement in Upstate New York is approximately $40.00 per patient, per calendar month.
99091 – Review of patient data by physician or qualified healthcare provider. Reimbursement in Upstate New York is approximately $55.00 per patient, per 30-day period.
When considering whether remote patient monitoring is right for a healthcare practice, a physician should take a number of factors into consideration: each patient must be an active and willing participant who, with training, understands how to use the monitoring equipment; the ordering physician should specify ranges in which alerts should be filtered, responded to, and escalated on a patient-by-patient basis (one size does not fit every patient); documentation must be in place supporting each code that is billed; a trusted, HIPAA-compliant technology service should be implemented to receive, track, and report the remote patient data; and only monitoring devices that are proven to be reliable should be selected. Some physicians choose to use a full-service remote patient monitoring vendor program to handle the non-clinical aspects of the remote patient monitoring services in order to streamline the process.
Remote patient monitoring poses a broad opportunity for physicians to generate additional revenue under the appropriate circumstances. Although evidence for remote patient monitoring is somewhat limited, and the practice does involve some risks, many physicians believe it is an effective and worthwhile strategy for care management in certain patient populations.
Brigid M. Maloney, Esq. is aA Partner at the law firm Lippes Mathias in Buffalo, NY, Brigid M. Maloney, Esq. serves as Co-Leader of the firm's Health Law Practice, providing counsel to health care clients, including national digital health innovators, telehealth providers, remote patient monitoring companies, management services organizations and friendly PCs, single and multi-specialty medical practices, hospitals, behavioral health providers, human services agencies, med spas, medical call centers, physicians, dentists, and other licensed practitioners on structural, regulatory and reimbursement issues related to corporate formations, mergers, acquisitions, joint ventures, complex contractual arrangements and other affiliations and collaborative efforts.
Researchers Mobilize at Hospital’s “Front Door” to Expand Cancer Screenings
To find people who are behind on cancer screenings and then motivate them to follow through, an innovative team is leveraging the emergency department at Strong Memorial Hospital and other regional UR Medicine sites for a research project. The project is especially important David Adler, M.D., M.P.H. for the Rochester area, where cancer rates are higher than in New York state and nationally. According to data from the University of Rochester’s Wilmot Cancer Institute, if the 27-county region from which Wilmot draws patients were its own state, it would have the second highest cancer incidence in the U.S. behind Kentucky.
The researchers’ goal is to identify participants for studies that evaluate whether a text-message reminder tool is more effective than a standard referral for prompting individuals to get screened for cancer. Researchers are directing their attention to underserved people who visit the emergency room for any type of illness, using the wait time as an opportunity for education about cancer screenings.
In 2020, the same research team started its National Cancer Institute-funded project by identifying urban and rural women who were in need of screening for cervical cancer, a preventable disease. At the time, researchers said they planned to expand their project — and this year they’ve included colon and lung cancer, two common malignancies for which screening can improve survival.
Why the emergency department?
“The ER takes care of people from all walks of life, from the most fortunate to the least,” said David Adler, M.D., M.P.H., professor of Emergency Medicine and Public Health Sciences at the University of Rochester Medical Center, and a Wilmot Cancer Institute investigator who co-leads the projects. “It’s a place to reach the uninsured, the underinsured, and people who generally have little or no access to health care, including people of color, recent immigrants, and those with language barriers,” he said.
Co-investigator Beau Abar, PhD, noted that the emergency department is a hospital’s “front door,” as more than 70 percent of patients needing inpatient hospital care come through the emergency room. “Our project is also timely, given that the COVID-19 pandemic has resulted in dramatic increases in missed cancer screenings,” said Abar, an associate professor of Emergency Medicine, Public Health Sciences, and Psychiatry.
Routine cancer screening
Adhering to scientific guidelines for cancer screening can lead to early detection of the disease, making it more treatable. Receiving accurate information from health care providers can also ease fears and debunk myths.
For example, Abar said, a colonoscopy is not the only way to screen for colorectal cancer. Other options include the less invasive sigmoidoscopy or annual stool tests. It’s important that individuals find the best option by consulting a physician. • The colon cancer study involves referring qualified individuals to a physician to coordinate the screening test and sending text messages to encourage follow-up. • The lung cancer screening study is similar: researchers engage people who are eligible for a low-dose CT scan to screen for lung cancer and then will evaluate which method works best to encourage patients to complete the process. Through UR Medicine’s Lung Cancer Screening Program, patients can get screened
in Rochester and in the region, including Brockport, Canandaigua, Dansville, and Hornell. • Early data from the cervical cancer study show that the percentage of women who lack adequate screening is higher in the Rochester region than national averages, demonstrating a great need for cancer prevention services, education, and research, Adler said. Most cases of cervical cancer and related deaths occur in women who have not been screened with routine pap tests.
Adler, Abar, and their team recently received a University of Rochester Research Award to gather pilot data for colon screening and a URMFG Healthcare Innovation two-year pilot award for the lung cancer study. Nancy Wood, MPA., MS, is the project manager. The team collaborates with Wilmot’s Cancer Prevention and Control research program and its Community Outreach and Engagement office.
Screening for Colon Cancer
• Colon cancer is becoming more common and deadly. It is the third most common cancer in the U.S., and the third leading cause of cancer deaths. • Colon cancer almost always develops from precancerous colorectal polyps, which, in many cases, can
be detected and removed before they turn into cancer. • Adults ages 45 to 75 should be screened for colon cancer, but millions of people in the U.S. do not adhere to this recommendation. • Checking for cancer when a person has no symptoms is best. If cancer is found at this stage, it is often easier to treat.
Screening for Lung Cancer
• Lung cancer is the number one cause of cancer deaths in the U.S. • Individuals are eligible for a low-dose chest CT to screen for cancer if they are 50 to 80 years old, have smoked a pack a day for 20 years or two packs a day for 10 years (or more), and either still smoke or have quit within the last 15 years. • The guidelines were developed by the U.S. Preventive
Services Task Force (USPTF), which has also called for prioritizing lung cancer screening for vulnerable, underserved people. • Studies show that lung cancer screening and early detection can lead to better outcomes for patients.
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Roswell Park Researchers Identify Key Link Between Stress and Cancer
Stress pathway involving beta-adrenergic receptors fuels tumor growth
Elizabeth Repasky, PhD Hemn Mohammadpour, PhD, DVM
Stress can have a significant negative effect on health, but our understanding of how stress impacts the development and progression of cancer is just beginning. A team from Roswell Park Comprehensive Cancer Center has identified an important mechanism by which chronic stress weakens immunity and promotes tumor growth. Their findings, just published in Cell Reports, point to the beta-adrenergic receptor (B-AR) as a driver of immune suppression and cancer growth in response to stress, opening the possibility of targeting this receptor in cancer therapy and prevention.
Using a preclinical model of triple-negative breast cancer, a research team led by Hemn Mohammadpour, PhD, DVM, a postdoctoral research affiliate in the lab of Elizabeth Repasky, PhD, and Dr. Repasky, who is Co-Leader of the Cell Stress and Biophysical Therapies Program and the Dr. William Huebsch Professor in Immunology at Roswell Park, found that as tumors grow, they become more sensitive to stress signals coming from the nervous system. Specifically, the researchers discovered that a population of immune cells known as myeloid derived suppressor cells (MDSCs) show an increase in the expression of B-AR, a molecule that controls the function of key immune cells.
Elizabeth Repasky, PhD, left, and Hemn Mohammadpour, PhD, DVM, immunology researchers from Roswell Park, report new findings about the role certain immune cells play in affecting response to cancer treatment.
The findings will help researchers better understand why prolonged exposure to stress often makes our immune system less effective, and build on Roswell Park’s pioneering research into the relationship between stress and cancer. “This increase in B-AR expression on myeloid-derived suppressor cells allows these cells to be stimulated by the stress hormone norepinephrine, which fosters an immunosuppressed environment that promotes tumor growth by increasing MDSC’s ability to generate and process energy and suppress anti-tumor immune response,” says Dr. Mohammadpour, the paper’s first author. “This study provides some very important clues that help explain the specific mechanisms by which prolonged stress stimulates tumor growth and decreases lifespan.”
While there has been a longstanding recognition that long periods of stress, or chronic activation of nerves, are harmful to overall health, details about how this occurs are unclear, especially in the setting of cancer. A better understanding of the specific ways in which stress influences cancer, particularly in terms of lowering immunity against tumor cells, could be used to design new drugs or therapies that can help to minimize negative effects of chronic stress and boost cancer immunotherapy.
Based on these findings, Dr. Repasky’s team is planning new clinical and laboratory studies to identify therapies — including existing therapies already approved for other applications — that can block these harmful stress signals and stop the negative cycle of cancer growth and metastasis. “This is especially important for cancer patients, who frequently endure greatly increased levels of stress after their diagnosis, including anxiety, depression and worry about factors like finances and family interactions,” adds Dr. Mohammadpour.
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Researchers Aim to Prevent Lung Cancer With Latest CIMAvax-EGF Clinical Trial
Prevention study is recruiting lung cancer survivors as well as those at high risk due to smoking history
A groundbreaking international collaboration brought an innovative lung cancer immunotherapy from Cuba —CIMAvaxEGF— to Roswell Park Comprehensive Cancer Center. Now researchers at the Buffalo-based center are now examining whether this immunotherapy developed to treat lung cancer might prove to be an effective tool for preventing the often-deadly disease.
Led by Mary Reid, MSPH, PhD, the interventional earlyphase clinical trial is currently recruiting for participants who fall into two groups, or cohorts — middle-aged individuals who currently smoke or have quit smoking within 15 years and carry other lung cancer risk factors like COPD, family history of the disease or have high-risk occupational exposures but have not been diagnosed with cancer AND lung cancer survivors who have completed treatment. “If you’ve had lung cancer and survived it, your biggest fear is that the tumor is going to come back, and we’d like to do anything we can to prevent that,” said Dr. Reid, who is also the Chief of Screening, Survivorship and Mentorship at Roswell Park. “I think CIMAvax has shows great potential to help this group as well as individuals who are past or current smokers at risk for lung cancer.”
This immunotherapy works by blocking a protein known as epidermal growth factor (EGF), which lung cancer cells need to grow. CIMAvax produces antibodies against EGF, mounting an immune response, capturing the protein so that it no longer circulates in the blood and no longer reaches the cancer cells. The cells end up “starved,” as the protein cannot connect to its receptor, known as EGFR, on the cell and cancer growth is inhibited. Previous studies have shown that EGFR has been found in the airways of cancer-free subjects as well as people diagnosed with cancer. Dr. Reid and team are looking to learn whether the antibodies created by CIMAvax may drive down the risk for developing lung cancer. “No one deserves to get lung cancer,” says Dr. Reid. “We need to offer people something to reverse damage done by smoking exposure. If we could have an easy-to-administer medication someone can get on an outpatient basis that could prevent them from progressing to cancer — that would be a quality-of-life game-changer. So we’re exploring whether CIMAvax has that potential.”
CIMAvax-EGF has been developed over the course of more than 25 years by researchers at the Center for Molecular Immunology (CIM) in Havana, Cuba. The CIM is currently conducting an identical prevention study in their country.
For full study and enrollment details, please visit the CIMAvax page on the Roswell Park website or call 1-800-ROSWELL (1-800-767-9355).
Building on Prior Research, Wilmot Makes Progress on Vexing Liver Cancer
By Leslie Orr
David Linehan, M.D
Individuals diagnosed with intrahepatic cholangiocarcinoma (iCCA), a type of liver cancer, face a five-year survival rate of less than 10 percent. But a Wilmot Cancer Institute team that also investigates pancreatic cancer, which has similarly poor survival statistics, discovered factors that both aggressive cancers have in common. Scientists believe the new data provide a roadmap for targeting the tumors with immune therapies.
In a recent publication in the journal Gut, the team showed that iCCA tumors are comprised of a dense network of cells that are non-cancerous and yet help to create an environment that’s ripe for cancer’s growth and spread. Called TAMs (tumorassociated macrophages), these same cells also play a sinister role in pancreatic cancer.
The TAMs create an inflammatory barrier around cancer cells that block the body’s natural disease fighters (such as T cells) from destroying the cancer. Patients with iCCA whose tumors are infiltrated with TAMs have a poorer prognosis, the paper stated. First author is Luis Ruffolo, M.D., a surgical resident at URMC.
This image shows how the green cancer cells are protected by the red TAMs.
Researchers also developed new laboratory methods to advance the studies, which are led by David Linehan, M.D., chief of clinical operations at Wilmot and the Seymour I Schwartz Professor and chair of Surgery at the University of Rochester Medical Center.
Linehan and collaborators have been investigating TAMs for many years and are working on combinations of therapies that can break through the juggernaut of resistance. The latest paper lays out how TAMs are recruited to the tumor site; it also demonstrates in mice that blocking those recruitment pathways depletes TAMs and allows T cells to activate against iCCA.
Intrahepatic cholangiocarcinoma arises in the bile ducts inside the liver and usually occurs in adults ages 50 to 70. It is part of a group of biliary tract cancers (gallbladder, for example) and is often treated with chemotherapy. More recently, scientists have discovered that iCCA is a diverse genomic disease with the potential for new, targeted immunotherapy options.
ROSWELL PARK Roswell Park Experts Share Insights on Diagnosis and Treatment of Head & Neck Cancers at AHNS 2021 Team outlines strategies to improve treatment of oral and thyroid cancers at American Head & Neck Society meeting
With the international community of experts in headand-neck cancers gathering virtually to share new ideas and treatment strategies at the American Head & Neck Society (AHNS) 10th International Conference on Head and Neck Cancer, underway now, Roswell Park Comprehensive Cancer Center teams are presenting new research on both the basic science supporting new treatments as well as opportunities to improve the early and accurate diagnosis of thyroid cancer and other head/neck malignancies.
Among the 17 presentations of new research led by Roswell Park’s head/neck cancer experts, representing several
disciplines and expertise in both clinical and laboratory research, are three studies that may lead to development of new and more effective drugs and treatments for oral-cavity cancers and another trio of studies focused on improving the diagnosis and treatment of thyroid cancers. “This is an exciting time for all of us who are working to improve the care and outcomes of patients with cancers of the head and neck, because we’re able to take advantage not only of improvements in diagnostics and traditional therapies but the incredibly detailed understanding we now have of processes at the molecular level,” says Wesley Hicks Jr., MD, FACS, Chair of Head & Neck/Plastic & Reconstructive Surgery at Roswell Park. “Our latest work presented at AHNS identifies several opportunities to apply next-generation insights, and we’re proud to help shape these conversations and advance the care of cancer patients everywhere.”
To support their studies in oral cancer, the team applied two distinct approaches to advance the understanding of activity in the microenvironment of oral-cavity tumors: • The team used immunohistochemical analyses to (1) characterize a type of regulatory T cell that supports tumor growth and impedes immunotherapy and (2) analyze tumor expression of the NY-ESO-1 antigen in oral cavity dysplasia and carcinoma, showing that presence of this protein increased during tumor development. (Abstract P020 and Abstract P038) • For another study, the team examined the role that exosomes — small vesicles secreted by tumor cells — play in interfering with chemotherapy and immunotherapies, demonstrating that they increase in abundance as cancer progresses. (Abstract P031)
In three separate projects addressing thyroid cancer incidence, detection and diagnosis, Roswell Park researchers report that: • Core needle biopsy, the diagnostic tool used most frequently in Roswell Park’s head/neck cancer practice, correctly diagnosed thyroid cancer and identified an especially aggressive subtype, tall cell variant (TCV) papillary thyroid carcinoma, more frequently than an alternative diagnostic approach, fine needle aspiration (FNAC). (Abstract P203) • TCV papillary thyroid carcinoma has been diagnosed more frequently among patients seen at Roswell Park, compared to national incidence rates, and this aggressive subtype requires close post-treatment surveillance. (Abstract P172) • Lectins, naturally occurring proteins present in many plant-based foods, represent a promising biomarker candidate that may be able to help distinguish different subtypes of thyroid cancer to support the most appropriate and personalized treatment strategies for each individual patient. (Abstract P136)
“We’re seeing increasing numbers of aggressive thyroid cancers in our practice at Roswell Park,” says Vishal Gupta, MD, Assistant Professor of Oncology and Otolaryngology in the Department of Head & Neck/Plastic & Reconstructive Surgery at Roswell Park. “Through this trio of studies, we’re working to quickly identify, characterize and address this apparent trend to help guide treatment and follow-up for patients with especially aggressive or hard-to-diagnose thyroid tumors.”
Roswell Park Team Shows Dendritic-Cell Vaccines Can Be Paired with Standard Therapy for Breast Cancer iPSC-derived dendritic cells can work synergistically with radiation therapy to control both local and distant tumors
A research team led by Fumito Ito, MD, PhD, FACS, of Roswell Park Comprehensive Cancer Center reports new data on the promise of combining standard treatment for breast cancer with a particular form of cancer immmunotherapy — dendritic-cell (DC) treatment vaccines. This study, published in the Journal for ImmunoTherapy of Cancer, is the first to demonstrate that in situ dendritic-cell vaccines can improve the effectiveness of radiation therapy for some aggressive and treatment-resistant forms of breast cancer. “Although immunotherapy with primary conventional dendritic cells is a promising approach, obtaining a sufficient
Fumito Ito, MD, PhD, and colleagues have shown that dendritic-cell treatment vaccines can be combined with radiation therapy as a potential treatment for some breast cancers.
number of circulating conventional dendritic cells has proved difficult,” says Dr. Ito, who is Associate Professor of Surgical Oncology at Roswell Park. Use of induced pluripotent stem cells (iPSCs) has been proposed to overcome that Tompkins Healthcarelimitation, but the feasibility of this approach had not previously been Services Suite demonstrated.
To better understand the potential Building Healthcare Practices, Togetherof this approach, Dr. Ito and colFor Doctors, Dentists and Veterinarians leagues conducted laboratory studies to assess the antitumor efficacy of intratumoral injection of iPSC-DCs, or dendritic cells derived from iPSCs, and radiotherapy in models of triplenegative breast cancer that have shown resistance to anti-PD-L1 checkpoint Healthcare professionals are crucial to the strength inhibition immunotherapy. of our communities. When planning your financial
The team’s results show that intra- strategy, consider the difference Tompkins Bank of Castile tumoral administration of iPSC-DCs can provide as you work toward building your practice. significantly enhanced antitumor efficacy of local irradiation, which is commonly incorporated into treatment plans for patients with breast cancer.
The researchers demonstrate that radiation therapy increased the trafficking of intratumorally injected iPSC-DCs to the tumordraining lymph nodes and augmented the activation of tumor-specific T cells. Their work shows that this multimodal intralesional therapy can control growth of distant tumors and render some breast cancers responsive to anti-PD-L1 therapy “While our work to develop this strategy is at an early stage and will need to be studied further, we show that these two approaches, radiotherapy and intratumoral iPSC-DC administration, can work synergistically to control not only local tumor growth but also distant tumors. And we saw evidence of systemic tumor-specific immunological memory, suggesting a potential for long-term tumor control,” says Dr. Ito. This study sheds light on the antitumor efficacy of in situ administration of iPSC-DCs when integrated with radiotherapy against poorly immunogenic tumors. These findings align with another study from Dr. Ito and his team, recently published in Nature Communications, that showed potent systemic antitumor immunity caused by combinational multimodal intralesional therapy. “Currently, efficacy of immunotherapy against breast cancer is limited,” adds Dr. Ito. “Our hope is to improve clinical outcomes for patients with advanced unresectable and metastatic breast cancer.”
URMC URMC Part of Collaboration Awarded $10M for Pediatric Concussion Research
National trial will study biomarkers that predict delayed recovery in children, teens
Researchers at the University of Rochester Medical Center are part of a new collaborative project, led by the University of California, Los Angeles, to study concussions in children and teens. The project, which was awarded $10 million from the National Institute of Neurological Disorders and Stroke, will test ways to predict which kids will develop persistent symptoms after a concussion, so researchers can study how to help them recover faster.
The grant to the Four Corners Youth Consortium, a group of academic medical centers studying pediatric concussions, will support Concussion Assessment, Research and Education for Kids, or CARE4Kids, a multisite study that will enroll more than 1,300 children and teens nationwide, including an estimated 240 in the Rochester area.
Every year, more than 3 million people in the U.S. are diagnosed with concussions. Symptoms continue to plague 30 percent of patients three months after injury and adolescents face an even higher risk of delayed recovery. Chronic migraine headaches, learning and memory problems, exercise intolerance, sleep disturbances, anxiety and depressed mood are common.
The pre-teen and teen years are critical for psychosocial and brain development and researchers fear what long-lasting concussion symptoms could mean for the developing brain. “Prolonged concussion recovery can have an enormous impact on the lives of teens and pre-teens, often setting the stage for academic difficulties, persisting mood disorders, and chronic pain,” said Jeffrey Bazarian, MD, MPH, professor of Emergency Medicine at URMC, who will lead the Rochester study site. “Early evaluation and treatment for kids at high risk for prolonged recovery is our best hope for preventing an acute injury from becoming chronic.”
The study, which focuses on children between the ages of 11 and 18, will unfold in two phases. The first part will evaluate children with concussions to identify a set of biomarkers — including those related to changes in blood pressure, heart rate and pupil reactivity — that could predict which kids will develop persistent symptoms after a concussion. The next will seek to confirm that these biomarkers accurately predict prolonged symptoms in a second group of children diagnosed with concussions.
Ultimately, the team hopes to develop an algorithm to help healthcare providers diagnose and treat concussed kids and to enable the future development of therapies that could help kids recover from concussions faster. “Discovering objective biomarkers for persistent post-concussion symptoms will permit earlier intervention and future use of specific treatments for these patients,” said national project leader Christopher Giza, MD. director of the UCLA Steve Tisch BrainSPORT Program and professor of Pediatrics and Neurosurgery at UCLA’s David Geffen School of Medicine and Mattel Children’s Hospital. “Our big goal is to alleviate suffering and promote maximal recovery.”
Risk Management Tip: Managing Negative Online Reviews
The Risk
Healthcare providers recognize that along with their practice websites, public websites such as Yelp, Healthgrades, and Rate MDs, and social media sites like Facebook and Twitter, can be used as marketing tools to inform the public of their services. The online community, however, is then afforded an opportunity to respond, rate, and, at times, complain about those services. These statements and reviews are readily accessible to anyone with an internet-ready device to open and read.
While there is a basic instinct to immediately respond to negative online reviews, healthcare providers must remember that privacy rules make a complete response via social media inappropriate, and responding directly to an online post puts the healthcare provider at risk of disclosing protected health information (PHI). Your response may not contain any identifying statements, but the mere recognition of a patient-provider relationship is a potential HIPAA violation.
The following tips will help you successfully and appropriately respond to negative online reviews:
Recommendations
1. Critically review all social media posts for accuracy and authenticity. While some negative statements regarding the performance of you or your staff may be difficult to read, evaluate these reviews to determine if there is any opportunity for learning or process change. 2. Do not become engaged in online arguments or retaliation—especially if the comments made are particularly negative and potentially detrimental to the reputation of the facility or physician. 3. According to federal and state confidentiality and privacy laws, providers are precluded from identifying patients on social media. In order to protect patient privacy, all patient concerns and complaints should be resolved by the practice by contacting the patient directly and not through social media. 4. If you do choose to respond via social media, use a standard response that also serves as a marketing opportunity for your practice. Some examples include: • “[Insert name] Medical Group is proud to have been providing comprehensive and compassionate care in the community since [insert year] and takes our treatment of its patients and their privacy seriously. Because federal privacy laws govern patients’ protected health information, it is not the policy of [insert name] Medical Group to substantively respond to negative reviews on “ratings” websites, even if they provide misleading, unfair or inaccurate information. We welcome all our patients and their families to address any concerns/requests or information about their care with us directly, as we strive to continue to provide individualized care in our community.” • “At our medical practice, we strive for patient satisfaction. However, we cannot discuss specific situations due to patient privacy regulations. We encourage those with questions or concerns to contact us directly at [insert phone number].” 5. If you feel the patient’s complaint has disrupted the physician-patient relationship, consider discharging the patient from your practice. This action may be viewed as retaliatory by the patient and may set off a new series of negative posts. Attorneys at Fager Amsler Keller & Schoppmann, LLP are available to assist you to make this decision. 6. Notify your local authorities if you feel at any time that your safety, the safety of your staff or your family is threatened or at risk.
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