Banner MD Anderson Rounds - Summer 2014
A PUBLICATION FOR COMMUNITY PHYSICIANS SUMMER 2014 Interdisciplinary approach to lung cancer treatment Banner MD Anderson Cancer Center introduces the Comprehensive Lung Cancer Program BY MEGHANN FINN SEPULVEDA AGGRESSIVE APPROACH TO TREATMENT When it comes to lung cancer, staging and molecular test results determine prognosis. Pathologists perform molecular testing to see what makes the cancer tick on all Stage IV patients. “We consider patients with Stage I, II or III potentially curable,” Wagner says. “Typically Stage IV patients with defined driver mutations do well on oral drugs and can beat the average survival rate of 10-12 months.” For Stage IV patients with few metastases, treatment goes beyond the traditional methods and could involve consolidation radiation or surgery, in combination with induction chemotherapy or oral agents, which can increase the outcomes while providing symptom control. “I am currently not undergoing any treatment following a year of chemotherapy and radiation,” Arias says. Arias is a Stage IV lung cancer patient. “I am fully aware of what my outcome will be, but today I feel good.” Arias receives a CT scan every three to four months. Her last scan in December was clear. L ung cancer patients can benefit from Banner MD Anderson Cancer Center in Gilbert’s new Comprehensive Lung Cancer Program, a unique collaboration between a multidisciplinary team of physicians and specialists, who work together to create a more effective, consistent and safer approach to treatment, which results in improved aoutcomes. According to the American Cancer Society, lung cancer is the second most common cancer among men and women. INDIVIDUALIZED MEDICINE Under the care of dedicated physicians at Banner MD Anderson’s Comprehensive Lung Cancer Program — which includes a medical oncologist, radiation oncologist, thoracic surgeon, pathologist and pulmonologist — this is far from a fragmented approach to care. “The medical team meets once a week to review the complexities of each patient and align strategies to determine the treatment plan,” says Klaus Wagner, M.D., PhD, medical oncologist, Banner MD Anderson. “We care for each patient on an individualized basis to maximize outcomes.” And it’s all done under one roof. “It’s very nice to have all my tests, blood work and scans right there,” says Banner MD Anderson patient Aldean Arias, 72, of Mesa. “It’s very convenient.” Lung cancer patients no longer need to worry about traveling between appointments and can avoid miscommunication between their team of physicians. Test results are viewed faster, leaving less room for error. INSIDE 3 Integrated oncology 4 Radiation oncology 6 Radium-based therapy 7 The brachytherapy alternative 8 Banner MD Anderson physicians NEW TREND OF YOUNGER PATIENTS While the patient demographic is usually in the age range of 70-80 and includes smokers, there is a wide spectrum with younger patients being treated for lung cancer who have never smoked. There is no scientific evidence that points to the cause of lung cancer in non-smokers, but experts say that environmental factors may be to blame. “These patients have likely been exposed to radon, radiation, or air pollution, including industrial or automotive, or have inhaled other harmful chemicals,” Wagner says. The American Cancer Society claims people are exposed to radon inside buildings and homes via pipes or cracks, and outdoors through soil and water. Arias quit smoking 26 years ago. She was born and raised in Globe, Ariz., where she was potentially exposed to radioactive contamination during nuclear testing that took place in southern Nevada in the 1950s. “We’ll never know if that caused my lung cancer, but the facts are there,” Arias says. CLINICAL RESEARCH Several attractive clinical trials have opened up for lung cancer patients at Banner MD Anderson’s Comprehensive Lung Cancer Program. “There haven’t been a lot of clinical studies that are solely dedicated to treating lung cancer patients here in the Valley,” Wagner said. “We are looking towards encouraging results with new cancer immunotherapy strategies for our metastatic Stage IV patients and will open up two of these clinical trials soon.” Arias has a positive outlook on her life. “I am focused on having the strength to make this journey and having the peace to walk it,” she said. For more information on Banner MD Anderson’s Comprehensive Lung Cancer Program, visit BannerMDAnderson.com. — Klaus Wagner, M.D., medical oncologist We care for each patient on an individualized basis to maximize outcomes. Meet the docs Banner MD Anderson Cancer Center’s Comprehensive Lung Cancer Program lung program is led by: Klaus Wagner, M.D., PhD, is a medical oncologist at Banner MD Anderson in Gilbert, who focuses on thoracic and head and neck malignancies, and early clinical drug development. Besides treating cancer patients, Wagner is the local principal investigator of four lung cancer trials and performs translational research. Wagner is trained as a physicianscientist. He received a medical degree and PhD from the Friedrich-Alexander University Erlangen in Germany. He completed a fellowship in medical oncology at The University of Texas MD Anderson Cancer Center in Houston, TX. Dr. Klaus Wagner and Dr. Daniel Chamberlain Ronald Servi, D.O., is a pulmonologist at Banner MD Anderson. Servi graduated from the Philadelphia College of Osteopathic Medicine. He then completed an internship at the Hospital of Philadelphia College of Osteopathic Medicine and a residency in Internal Medicine at Geisinger Medical Center in Danville, Pa. As a board certified pulmonologist, Servi completed a fellowship in pulmonary medicine at the University of New Mexico in Albuquerque. Prior to joining Banner MD Anderson, he was in private practice for 20 years in Phoenix. Daniel Chamberlain, M.D., is a radiation oncologist at Banner MD Anderson. Chamberlain received his doctor of medicine from Colombia University in New York in 2005. He completed postgraduate training in radiation oncology at Yale University School of Medicine. Chamberlain is actively involved in clinical research, has published several poster presentations on clinical outcomes and has co-authored articles that have appeared in international medical journal publications. To learn more about our physicians, visit BannerMDAnderson.com/OurPhysicians. 2 SUMMER 2014 ROUNDS Patients benefiting from Focus on evidence-based medicine improves outcomes, quality of life BY MEGHANN FINN SEPULVEDA integrative oncology truly unique offering at Banner MD Anderson Cancer Center in Gilbert is the new integrative oncology program, a specialized approach incorporating lifestyle and complementary strategies into cancer treatment. The personalized program is designed for people at risk for developing cancer, patients undergoing treatment and cancer survivors. The goal is to give patients back a sense of control. A They collaborate with a team of experts to review and assess each cancer patient’s diagnosis to determine lifestyle needs and encourage social support. rently integrative oncology patients are only seen one day a week in clinic, but the program is expanding. We are very busy and hope to begin seeing patients at least three days per week in the fall.” INTEGRATIVE THERAPIES Integrative oncology includes safe and effective evidence-based alternative medical treatment strategies that work to heal the entire body. “Patients greatly enjoy and benefit from therapies such as acupuncture,” Rao says. “In combination with chemotherapy, it has been extremely successful in helping with side effects such as nausea and neuropathy.” Additional techniques include yoga, meditation and breath work for pain, stress relief and fatigue, along with spiritual assessments. Caregiver support is also available. AT RISK PATIENTS For individuals considered at risk for developing cancer, cancer prevention consultations are a good opportunity to review cancer risks and determine prevention lifestyle recommendations, such as dietary modifications and incorporating physical activity into daily routines. Cancer survivors can significantly benefit from integrative oncology services. Coping mechanisms such as stress management and nutritional planning, along with reducing symptoms and side effects following treatment are all an integral part of the program. HIGHLY TRAINED A team of integrative oncologists specialize in what’s considered a very new holistic program that involves caring for the whole patient including the mind, body and spirit. “The program itself is unique,” says Santosh Rao, medical and integrative oncologist, Banner MD Anderson. “We are able to aggressively treat cancer patients with evidence-based medicine and also take into consideration lifestyle and social needs to ultimately improve outcomes and quality of life.” Diljeet Singh, M.D., gynecological oncologist and medical director of the program, and Rao are fellowship-trained in integrative medicine under the direction of Andrew Weil, M.D. Rao and Singh are two of only a handful of integrative oncologists in the country. TEAM COLLABORATION Patients who participate in the integrative oncology program remain under the care of their primary oncologist for ongoing treatment. The program is designed for patients seeking out complementary medicine treatment or at the recommendation of their physician. “We have a team approach,” Rao says. “We work together to determine the best plan of care for each patient. Cur- OUTLOOK ON FUTURE While integrative oncology is positively improving lives of cancer patients, there are challenges. “The main challenge is determining how we can make these treatments not only efficient but cost effective,” Rao says. “We are trying to develop a standard of care in the field of integrative medicine. We are confident in our ability to improve the quality of life for our patients.” BannerMDAnderson.com 3 He has published more than a dozen manuscripts in top journals, including JAMA. He has also authored several book chapters on lung cancer. He has been at Banner MD Anderson since the beginning of 2014; he came here from Houston because his extended family lives here. Shervin Shirvani, M.D. Dr. Sean Shirvani CAREFUL SELECTION At Banner MD Anderson, he is currently studying large population databases to compare the effectiveness of various treatment options for early-stage lung cancer, including conventional surgery, stereotactic radiosurgery, proton beam therapy and radiofrequency ablation. “There’s not a lot of will to enroll patients in randomized clinical trials for lung cancer,” Dr. Shirvani says. “Some physicians are uncomfortable with randomization because of strong opinions regarding which treatment is best.” Already, he adds, the research has yielded interesting findings. “If we adjust for patient and tumor factors, we find that stereotactic radiosurgery and surgery can yield equivalent outcomes for some groups of patients. This is important because a stereotactic approach is non-invasive and ambulatory and allows patients to forego the complications of surgery and general anesthesia. However, it is very important to select patients carefully for this procedure since some are still better served with an aggressive surgery.” Dr. Shirvani looks forward to caring for patients here and wants referring physicians to know that he is “happy to draw on my internal medicine background to help manage patients’ complicated medical issues such as diabetes or thyroid disease during the course of their oncology treatment as long as I have the referring physician’s blessing to do so.” Reach Dr. Shirvani at Shervin.Shirvani@bannerhealth.com. passion for care Banner MD Anderson Cancer Center radiation oncologist has background in internal medicine BY DEBRA GELBART Dual specialty, S hervin “Sean” Shirvani, M.D., M.P .H., is a radiation oncologist who provides care at Banner MD Anderson Cancer Center’s Radiation Oncology department at Banner Thunderbird Medical Center in Glendale. He knows that his background as an internal medicine physician helps him understand how important it is to primary care physicians that their cancer patients receive optimal care from specialists. “Primary care physicians can consider me a portal to excellent multidisciplinary care that carefully abides by the standards of The University of Texas MD Anderson Cancer Center in Houston,” he says. FINDING BETTER OUTCOMES “I make sure that a patient referred to me has received all necessary diagnostic and staging studies to properly characterize their disease and that all relevant specialists are involved before any treatment begins. That way, there are no burned bridges or lost opportunities for cure. We know that this approach results in better outcomes and higher levels of safety.” In fact, he adds, studies show that “when you use an up-front multidisciplinary approach, the patient’s survival rate can double when compared to a sequential approach of seeing multiple specialists.” Dr. Shirvani is a graduate of Duke University School of Medicine who began his medical career as a primary care hospitalist at Stanford Medical Center and San Mateo Medical Center in California. He became interested in radiation oncology as he cared for patients with cancer. He has an undergraduate degree in physics and he realized “that radiation oncology combines all of the things I like about taking care of patients in internal medicine with cuttingedge technology that draws on my knowledge of physics.” Dr. Shirvani completed his radiation oncology residency at MD Anderson and is double board-certified in internal medicine and radiation oncology. His research while he was in Houston focused on early-stage lung, breast and prostate cancers. 4 SUMMER 2014 ROUNDS Radium-based improving lives of late-stage prostate cancer patients Dr. Susan Passalaqua therapy BY BRIAN SODOMA A new injection therapy now being used at Banner MD Anderson Cancer Center in Gilbert, Ariz. is bringing hope to Stage IV prostate cancer sufferers. FDA-approved in June 2013, Xofigo (radium Ra 223 dichloride) was evaluated through a double-blind, randomized, placebo-controlled phase 3 clinical trial that included more than 900 patients with castrationresistant prostate cancer (CRPC) and symptomatic bone metastases. The trial revealed that Xofigo could delay the time to a patient’s first symptomatic skeletal event (SSE), and patients also reported significant pain relief. In November of last year, Dr. Susan Passalaqua, a diagnostic imaging specialist at Banner MD Anderson, started using Xofigo for some of her stage IV prostate cancer patients who did not respond to traditional hormone therapy treatments. The early results are encouraging. “Patients are saying their pain has been cut in half, they are taking less pain medication and their overall mobility has improved,” she said. Given as a monthly injection, Xofigo’s efficacy lies in the radioactive alpha particle’s ability to quickly travel directly to the area of the metastatic bone. To do so, Xofigo mimics calcium to form complexes with the bone mineral, hydroxyapatite, creating an anti-tumor effect on bone metastases. The particle emits a short traveling alpha particle, which limits damage to adjacent normal tissue. Passalaqua also finds the injection procedure to be convenient for patients. After properly hydrating with an IV, a one-minute injection delivers five cc’s of the radium tracer. Within five to 10 minutes, a patient is on his or her way home. Currently, a complete regimen of Xofigo is six monthly doses. Two patients in the Gilbert facility have had three doses so far, and a few others have had two months worth, Passalaqua said. But all are already reporting improvements in pain. The University of Texas MD Anderson Cancer Center in Houston, which was involved in the new drug’s randomized clinical trials, The drug has been approved earlier than expected because of the great responses seen in clinical trials. —Dr. Susan Passalaqua, diagnostic imaging specialist has patients who have seen full sixmonth courses. In time, after logging more results from full courses, the recommended length of treatment could change, Passalaqua added. Side effects seen are primarily gastrointestinal, and proper hydration is key to minimizing them. Xofigo will soon be tested in clinical trials involving breast cancer and metastatic osteosarcoma patients. “The drug has been approved earlier than expected because of the great responses seen in the clinical trials,” Passalaqua added. “I foresee this therapy potentially being used in a lot of other metastatic cancers in the future.” BannerMDAnderson.com 5 Instead of coming in for treatments for four to six weeks, a patient can come for 2 1/2 weeks, every other day, and be done. — Anna Likhacheva, M.D., M.P.H. Anna Likhacheva, M.D., M.P.H. her hands to create the custom molds that are sometimes needed to deliver the radiation to a targeted body part. “I like to think about each patient as a new clinical challenge, and how I can make the best possible outcome happen for that patient.” Brachytherapy is not a new form of radiation therapy; it has long been used to treat breast, prostate and head and neck cancers, among others, but its use in the treatment of skin cancer reaches back only a couple decades. Although all radiation therapy options are good, she says that brachytherapy’s big advantage is that it delivers a dose of radiation from a radioactive source, such as a seed containing Iridium-192, close to the surface of the skin and effective alternative for skin cancer patients Provides shorter treatment time, better patient outcomes BY GREMLYN BRADLEY-WADDELL Brachytherapy TARGETED RADIATION S kin cancer is the most common form of cancer in the U.S. and the world, and the standard treatment approach is surgical excision. For those patients who are unable to undergo surgery, however, radiation therapy is an excellent treatment option with high cure rates. Skin brachytherapy — one type of radiation therapy — is a new way of delivering radiation to the skin. The procedure’s shorter treatment time, compared to regular radiation, and its better cosmetic results are a few of the reasons that Anna Likhacheva, M.D., M.P.H., chooses to specialize in delivering this treatment. SUMMER 2014 ROUNDS “Brachytherapy provides excellent patient outcomes at low cost and with maximum patient convenience,” says the radiation oncologist at Banner MD Anderson Cancer Center in Gilbert, adding that she also likes working with Assessing surgical candidates The overwhelming majority of patients diagnosed with skin cancer will opt for surgery, but the fact is that not everyone is a candidate, and that’s often when brachytherapy is utilized. The following scenarios, according to Likhacheva, likely would exclude someone from being a candidate for surgery: • a history of a bleeding disorder, especially if the patient is older • an extensive lesion or a large number of lesions • poor vasculature, or blood vessels • history of poor healing from surgery • a cancer that keeps coming back in the same area • a cancer in parts of the body where surgery could lead to functional impairment , such as nose, ears, fingers, corners of the mouth, eyelids, etc. 6 directly to the site of the cancer. “That’s exactly what you want,” she says of the very precise approach. “You don’t want a dose going into deep tissues and unnecessarily irradiating vulnerable structures underneath the skin, and that’s what can happen when you use external beam radiation, the most common delivery form of radiation therapy.” What’s happening at s you know, part of being a great doctor is being a good listener. Good listening skills are essential to being a great medical institution as well. At Banner MD Anderson Cancer Center in Gilbert, we’ve been listening to our staff and our referring physicians. And what we heard is that we needed a more efficient intake process and improved communication with our doctors. We listened — and we acted. For those of you who haven’t met Veronica Campbell, you likely will in the months ahead. She joined our team late last summer as our Director of Physician Integration, and she serves as a conduit between our community physicians and Banner MD Anderson. She is here to make sure you have access to the resources you need for your patients and to connect you with the right people on our staff. She spends a lot of time in the community meeting with — and listening to — physicians. If you’re having challenges, let her know. Don’t know where to send a patient or what resources are available? Ask her. Plus, she’s here to be your voice as well, bringing information, concerns and suggestions back to Banner administration. One change she’s helped implement over the past several months is improving our intake process. We’ve made it easier for you to send patients Banner MD Anderson Cancer Center NON-INVASIVE Skin brachytherapy is also a noninvasive procedure, usually requiring a catheter or applicator for the placement of the seed, and it usually takes just a few minutes to complete each treatment. Since less subcutaneous tissue is irradiated, patients experience less scarring, less hypopigmentation (lightening of skin color) and fewer telangiectasias, or dilated blood vessels. In addition, because the procedure delivers radiation to such a precise area, a larger dose can be administered, Likhacheva said. That means fewer treatment sessions, a considerable convenience for the patient. “We can do 10 treatments instead of the usual 20 or 30 that are needed with external beam radiation,” she says. “So instead of coming in for treatments for four to six weeks, a patient can come for 2 1/2 weeks, every other day, and be done.” She emphasized, the vast majority of the 4 million people in the United States who are diagnosed with skin cancer each year and seek treatment should first be evaluated for surgery, which is the treatment of choice. Alternatives to surgery include topical chemotherapy and radiation, but it is generally accepted that radiation therapy has better outcomes. The percentage of skin cancer patients who opt for brachytherapy hovers in the single digits, but, even one percent of 4 million is a significant number, she said. A to us — and patients now get in faster than ever. If you have a patient to refer to us, start by calling our intake line at (480) 256-3433. We also have new, simple referral forms to aid in the process. To obtain the forms, contact Veronica directly at 480-543-2279 or Veronica.Campbell@ bannerhealth.com. And here’s the best part: With our improved process, patients will be able to see a Banner MD Anderson physician within three to five days of our receipt of your referral. We also heard that getting a hold of our physicians was challenging. We’ve made great strides in improving communications. Our doctors have agreed to make their cell phone numbers available to referring physicians. If you’d like a listing of our doctors and their cell phone numbers, contact Veronica and she’ll make sure you get a copy. These important steps are making a big difference in the lives of our referring physicians and our patients. And we hope to continue to improve our processes in the months and years ahead, so please be sure to connect with Veronica and let us know how we’re doing. Sincerely, Dr. Edgardo Rivera MEDICAL DIRECTOR BannerMDAnderson.com 7 BANNER HEALTH 1441 N. 12th SREET PHOENIX, AZ 85006-2887 NONPROFIT ORG U.S. POSTAGE PAID LONG BEACH, CA PERMIT NO.1677 INTRODUCING Banner MD Anderson PHYSICIANS B anner MD Anderson Cancer Center in Gilbert physicians are highly specialized in their fields of expertise. Below is a listing of physicians currently on our full time staff. Physicians continue to join Banner MD Anderson, so this list will continue to evolve. PATIENT REFERRALS To make a referral to a physician on our staff, please call 480-256-3433. To contact a member of medical staff, call 480256-6444 and ask for the physician to be paged. HEMATOLOGY & MEDICAL ONCOLOGY SECTION Tomislav Dragovich, MD, PhD, Division Chief Gorgun Akpek, MD, MHS Santosh Rao, MD Shakeela Bahadur, MD Mary Cianfrocca, DO Farshid Dayyani, MD, PhD Jade Homsi, MD H. Uwe Klueppelberg, MD, PhD Javier Munoz, MD Edgardo Rivera, MD, Medical Director Kerry Tobias, DO Rebecca Armendariz, MD Matthew Ulrickson, MD Klaus Wagner, MD PhD Bryan Wong, MD ONCOLOGY SURGERY SECTION Judith K. Wolf, MD, Division Chief Stephanie Byrum, MD Al Chen, MD Randall Craft, MD Mark Gimbel, MD Karen Pitman, MD, Matthew Schlumbrecht, MD, MPH Thomas Shellenberger, MD Diljeet Singh, MD Benny Tan, MD Julie Billar, MD RADIATION ONCOLOGY SECTION Matthew Callister, MD, Division Chief Dan Chamberlain, MD Emily Grade, MD Anna Likhacheva, MD Terence Roberts, MD Shervin Shirvani, MD DIAGNOSTIC IMAGING SECTION Donald Schomer, MD, Division Chief, CAQ Neuroradiology John Chang, MD, PhD Vilert Loving, MD Harvinder Maan, MD, CAQ Neuroradiology Rizvan Mirza, MD Susan Passalaqua, MD Andrew Price, MD, CAQ Interventional Radiology Philippe Lanauze, MD Jignesh Patel, MD CRITICAL CARE SECTION Shiva Birdi, MD, Division Chief Jijo John, MD Deven S. Kothari, MD Dean Prater, MD Ravindra Gudavalli, MD INTERNAL MEDICINE SECTION Nikunj Doshi, DO, Division Chief Shefali Birdi, MD Ronald Servi, DO PATHOLOGY SECTION Kevin McCabe, DO, Division Chief To learn more about our physicians at Banner MD Anderson in Gilbert , please visit BannerMDAnderson.com/OurPhysicians.