Digestive Trac • Spring 2012, Issue 2

DigestiveTrac Digestive Diseases • SPRING 2012 Issue 2

Inside this issue: Having A Regular Colonoscopy Saves Lives Advanced Endoscopic and Surgical Procedures Provide Minimally Invasive Options Chemotherapy and Radiation Therapy Provide Additional Treatment Genetics and Molecular Testing Determine Links to Colorectal Cancer Clinical Trials Of fers Alternative Treatment

Dear Colleagues, In accordance with Colorectal Cancer Awareness month, our March issue is dedicated to colorectal cancer. In this issue we will discuss the prevention, diagnosis, treatment, and follow-up care for colorectal cancer. In diagnosing and treating diseases of the digestive tract every day, the specialists at Avera Digestive Disease Institute are very aware and concerned about the serious nature of colorectal cancer and the many lives in our region this disease impacts.

Nationwide, approximately 147,000 new cases of colorectal cancer are diagnosed each year, and 50,000 people die of the disease. For both men and women, colorectal cancer is the third leading type of cancer, and the second leading cause of cancer deaths. Thanks to the latest screening technology – principally colonoscopy – colorectal cancer is one of the most preventable cancers.

By utilizing screening colonoscopy, our primary goal is to prevent colorectal cancer from ever happening by locating and removing precancerous polyps before they have the opportunity to develop into cancer. When malignancies do occur, we will provide an accurate diagnosis and begin treatment at the earliest stage possible to ensure the best possible outcome.

Dedicated to providing the highest quality care, our multidisciplinary team offers a full range of treatment services – including surgery, medical and radiation oncology, genetic testing and clinical trials. We invite you to take time to read about these specific aspects of our program in this issue.

As always, it is our privilege to work closely with primary care physicians for our patients’ best interest and continuity of care. This includes patients with colorectal cancer, polyps, or other malignant and non-malignant disease of the digestive tract, as well as patients with a family history of gastrointestinal malignancies. Please feel free to contact us at (605) 322-7797 with questions or for more information.

Sincerely,

Scott L. Baker, MD, FACS Colorectal Surgery Department Chair of Surgery Avera McKennan Surgical Institute of South Dakota

Steven Condron, MD, MHES, FACP Gastroenterology and Hepatology Avera Medical Group Gastroenterology

Co-Chairmen of Avera Digestive Disease Institute

Raising the Bar in Digestive Disease Care

Colonoscopy: The First Line of Defense This year, there will be approximately 147,000 new cases of colorectal cancer, and 50,000 deaths.

For both men and women, colorectal cancer is the third leading type of cancer, and the second leading cause of cancer deaths.

“Colon cancer is unique, because among cancers it is one that is largely preventable,” said Dr. Christopher Hurley, gastroenterologist with Avera Medical Group Gastroenterology. Most colon cancers grow from adenomatous polyps which develop into cancer over a period of 10 to 15 years. “If we remove those polyps during that window of time when it’s in a precancerous condition, the potential for cancer can be virtually eliminated,” added Dr. Hurley.

“Not every cancer is amenable to screening, but colon cancer is,” said Dr. Dany Shamoun, gastroenterologist with Avera Medical Group Gastroenterology.

“Studies demonstrate that people who are screened with a colonoscopy have a 90 percent reduced risk of developing colon cancer,” stated Dr. Steven Condron, gastroenterologist with Avera Medical Group Gastroenterology. Yet nationwide, only about 50 percent of people who are eligible for regular recommended screenings take advantage of them.

“Most colon cancers peak at age 60,” instructed Dr. Cristina Hill Jensen, gastroenterologist with Avera Medical Group Gastroenterology. “It is a very slow growing evolution from a polyp, and so we begin screening 10 years earlier.” About 25 percent of men and 20 percent of women who are screened do have benign polyps growing in the colon.

Starting screenings at the age of 50 is recommended, because that’s what makes the most sense in terms of risk, benefits and cost; however, earlier screening are recommended for those with a family history of colon cancer, those of African American heritage, or those who are subject to other risk factors.

There are a number of possible screening tools for colon cancer, but colonoscopy is recommended above other options such as CT colonography, barium enema, flexible sigmoidoscopy or fecal occult blood tests.

“Colonoscopy is the most sensitive test for detecting colon polyps because it examines the entire colon and gives the best visibility of any abnormalities.

At the same time, the endoscopist can remove any precancerous polyps. It is simply the best test for detection and treatment of colon polyps,” Dr. Hurley said. “During colonoscopy, when we identify polyps and remove them, we stop the process of colon cancer development and prevent the need for future surgery and chemotherapy. Of all the screening tests, colonoscopy is the most cost effective,” Dr. Condron added.

During a colonoscopy, the endoscopist can identify and biopsy suspicious lesions. “Our primary goal is to prevent colon cancer from happening, but if that’s not possible, we want to catch it early before it becomes metastatic,” said Dr. Shamoun.

Avera Medical Group Gastroenterology has taken steps to make screening colonoscopy as accessible, comfortable and private as possible for patients. They

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also provide open access for referring physicians and clinics. Endoscopic suites on the fifth floor of Plaza 1 on the Avera McKennan campus have less of a “hospital” feel and are more like a physician’s office. Patients who meet screening recommendations can set up their appointment by calling 605-322-7797, or a physician can call to schedule a procedure.

“Most patients say the worst part of the procedure is the colon prep the night before,” stated Dr. Hill Jensen.

A variety of options exist which make colon prep more tolerable for patients, she added. Because patients are usually sedated during the procedure for comfort and relaxation, they often don’t remember it.

“Through Avera’s Electronic Medical Record, referring physicians receive prompt documentation of the test,” Dr. Condron said. “We follow up on pathology to make sure the patient is aware of any findings.” Patients are also tracked, and receive notification when they are due for follow-up screenings.

Dr. Christopher Hurley performing a screening colonoscopy

“The specialists in our clinic are very experienced and have a high success rate with removal of difficult polyps and finding cancers. Our priority is to help eliminate colon cancer by increasing accessibility for recommended screenings,” Dr. Hill Jensen said.

Is it possible to use an alternative bowel prep?

We have multiple options available. Most patients have significant concerns regarding the volume of the bowel preparation. All preparations require significant ingestion of liquid. We can alter the regimen significantly to accommodate the patient’s needs. The patient’s kidney function and underlying comorbidities need to be carefully considered when developing the appropriate bowel preparation regimen. Our nursing staff has significant experience in helping patients and families navigate through this experience.

Why can’t my patient undergo CT colonoscopy?

This procedure, while very attractive in concept, is in development and not frequently reimbursed by payors. Typically, a failed colonoscopy needs to be documented prior to attempting preauthorization for a CT colonography. Additionally, patients are still required to undergo bowel preparation, and colon polyps cannot be removed during this procedure. Because of these limitations, the Centers for Medicare and Medicaid Services (CMS) have been unwilling to pay for this procedure without specific documentation. We have had significant difficulties in getting preapproval for this procedure in the recent past. This procedure and the process required for payment is in active evolution and will undergo significant modifications in the coming months and years. As it currently stands, colonoscopy is still considered the ideal management strategy given the ability to identify small lesions and remove them in one setting.

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Advanced Endoscopic and Surgical Procedures Provide Minimally Invasive Options Traditionally, the treatment of colorectal cancer involves a large incision and an open procedure, accompanied by a long hospital stay.

Yet advanced procedures offered through Avera Digestive Disease Institute allow physicians to remove tumors or correct other issues surgically through minimally-invasive techniques.

Examples include gastrointestinal endoscopic mucosal resection (EMR), laparoscopy, single-incision laparoscopic surgery (SILS), and combined endoscopic laparoscopic surgery (CELS).

“Gastrointestinal endoscopic mucosal resection (EMR) is an advanced endoscopic procedure to remove cancerous or other abnormal tissues from the digestive tract”, said Dr. Steven Condron, gastroenterologist with Avera Medical Group Gastroenterology, who takes a special interest in therapeutic endoscopy and advanced endoscopic procedures.

During EMR, a scope equipped with a light, video camera and other instruments is passed into the upper digestive tract through the esophagus, or into the colon through the anus.

EMR can be used to remove abnormal tissues such as early-stage cancer and precancerous lesions, and it can also be used to collect tissues for use in diagnosis. If cancer is present, EMR can help determine if the cancer has invaded tissues beneath the digestive tract lining.

“Endoscopic mucosal resection is a less invasive alternative to surgery for removing abnormal tissues from the lining of the digestive tract, in the case of early-stage malignancy or a precancerous condition,” Dr. Condron added.

If standard colonoscopy or EMR is unsuccessful at removing polyps, laparoscopy can often be used. “Even with today’s minimally-invasive technology, some 80 percent of colorectal surgical cases nationwide are still open procedures,” said Scott Baker, MD, surgeon with Surgical Institute of South Dakota, who is fellowship trained in colorectal surgery. With his specialized training, Dr. Baker rarely performs an open procedure.

“What has evolved is laparoscopy,” in which the patient receives two small incisions, and an incision in the navel.

“Laparoscopy has revolutionized the way we perform colorectal surgeries,” added Dr. Baker. In comparison, open abdominal surgery results in longer hospital stays, more pain, and greater risk of complications such as blood loss and infections. With

Dr. Steven Condron performing CELS with Dr. Scott Baker

laparoscopy, length of stay is often cut in half, from an average of eight days after an open abdominal procedure, to three to four days after a laparoscopic procedure. The patient also has only a few small scars as opposed to one large incision.

While easier on the patient, laparoscopic colectomy is a complex procedure for the surgeon to perform. It requires working in multiple quadrants of the abdomen at the same time. Unless there are multiple adhesions or a very large tumor, most colon resection cases can be performed laparoscopically by an experienced surgeon.

“The next wave is single incision laparoscopy surgergy (SILS),” stated Dr. Baker. This procedure involves one small incision in the navel, with all instruments being placed through this central port. “It’s really cosmetic surgery because there is no visible scar,” he added. “Through advancements like SILS and robotics, minimally invasive techniques will only improve patient outcomes.”

SILS can also be used in the removal of large or low lying polyps in the rectum that cannot be removed during a colonoscopy.

“A new surgical technique offered is transanal removal of polyps through the anus instead of through the navel or open abdominal incision. The patient’s recovery time is significantly less, allowing the patient to go home that day versus a several day inpatient stay,” said Dr. Baker. Because of the complexity involved in this type of surgery, fellowship training and experience results in better outcomes.

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“As with many types of surgery, studies have shown that outcomes are better in surgeries performed by a surgeon who specializes in that type of procedure,” Dr. Baker added.

Combining endoscopy and laparoscopy approaches takes advantage of both minimally invasive technologies. Drs. Baker and Condron collaborate to provide combined endoscopic laparoscopic surgery (CELS). Using a CO2 insufflation unit, physicians can switch between a laparoscope and colonoscope or perform combined procedures in the operating room.

This technology uses carbon dioxide insufflation instead of air during advanced laparoscopic procedures. Insufflation with air results in prolonged bowel distension and limits the space within the abdomen for laparoscopy. The rapid absorption characteristics of CO2 from the bowel lumen has opened new possibilities for intraoperative endoscopy immediately before, during, or after a surgical procedure to visualize and evaluate the intestinal lumen; identify and treat polyps, tumors, or bleeding sites; or check for anastomic leaks.

“This technique has the potential to improve patient outcomes as well as reduce pain and discomfort normally associated with air insufflation during endoscopic procedures,” Dr. Baker said.

One common application for this procedure is in the treatment of patients with difficult polyps. This includes polyps that cannot be removed during a routine colonoscopy because the polyp is too large or cannot be visualized. “Select patients with these types of conditions may benefit from this procedure instead of surgical resection,” Dr. Condron said. A colonoscopy is initiated at the beginning of the procedure, minimizing bowel distention.

Then a laparoscopic surgeon makes small incisions in the abdomen, maneuvers the colon and/or invaginates the wall of the colon, allowing the endoscopist to remove the polyp. Drs. Baker and Condron have performed several of these procedures at Avera.

Evolution of Surgical Management of Colon Cancer

1

2

Open Procedure

3

Hand Assist

4

Laparoscopy

SILS

Green lines indicate lenght of incisions which have dramatically decreased over time.

Dr. Scott Baker performing CELS with Dr. Steven Condron

Fellowship Training Produces Improved Surgical Outcomes Dr. Scott Baker, surgeon with Surgical Institute of South Dakota, is a fellowship trained colorectal surgeon who ensures unparalleled judgment in and out of the operating room. He performs an exceptionally high volume of colon resection and applies the most advanced techniques to the successful treatment of colorectal cancer.

The benefit of this additional training is evident in outcomes. “Data for colorectal cancer indicates that there are fewer colostomies and better management overall when the surgeon has been fellowship trained,” said Dr. Baker, who works in collaboration with the Avera Digestive Disease Institute.

Some 85 percent of Dr. Baker’s surgical practice is comprised of colon resection – removal of all or part of the large intestine in the treatment of both malignant and benign disease. Approximately 40 percent of those cases involve colorectal cancer.

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Chemotherapy and Radiation Therapy Provide Adjuvant Therapy for Colorectal Cancer In addition to surgery, medical oncology and radiation oncology provide important weapons in the arsenal against colorectal cancer.

Most stage I cancers that are surgically resectable do not require further treatment beyond surgery; however, adjuvant chemotherapy is recommended as part of the treatment regimen for patients with stage II, III and IV colorectal cancers. Radiation oncology may also be recommended if the size and/or location of the tumor warrants.

Dr. Addison Tolentino, medical oncologist and hematologist with Avera Medical Group Oncology & Hematology, said that in earlier stage cancers, chemotherapy helps prevent recurrence by killing remaining cancer cells. “Chemotherapy with stage II cancer remains a field of study,” he said. “Although most stage II patients will not have a recurrence, there is a subgroup with a certain type of cancer that places them at a higher risk for recurrence.

Genotyping is used to identify members of this subtype so appropriate treatment can be provided.”

“At stage III, there is a definite protocol for undergoing chemotherapy,” Dr. Tolentino said. At stage III, the cancer has spread to the lymph nodes, and/or to nearby tissues. “According to our literature, treating patients at stage III with chemotherapy will reduce recurrence by at least one-third,” he said.

“Stage IV is a subgroup that will not be cured, but is treated with chemotherapy to decrease the chance of early death from cancer,” Dr. Tolentino said. Palliative chemotherapy is an option to provide relief from symptoms when the cancer has metastasized to other organs, or when the cancer is considered incurable at the time of initial diagnosis or surgery. In such cases, chemotherapy, including molecular agents, may shrink the tumor and slow its growth.

Because colorectal cancer is a less aggressive tumor type, chemotherapy treatments can be drawn out to make them easier to tolerate. Common side effects are diarrhea, mouth sores, neuropathy, sensitivity to cold, fatigue and low blood count.

STAGE 1

STAGE 2

The cancer has grown into the inner wall of the colon or rectum.

The tumor has not yet reached the outer wall of the colon or extended outside the colon.

The tumor extends more deeply into or through the wall of the colon or rectum. It may have invaded nearby tissue, but cancer cells have not yet spread to the lymph nodes.

COLON AND RECTUM CANCER STAGING FORM STAGE 3 The cancer has spread to nearby lymph nodes, but not to other parts of the body.

STAGE 4 The cancer has spread to other parts of the body, such as the liver or lung.

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“Treatment options are individualized based on the tumor size, location and stage of the cancer,” said Dr. Kathleen Schneekloth, radiation oncologist with Avera Medical Group Radiation Oncology Dr. Addison Tolentino

While the more mobile segments of the colon are treated surgically, when cancer is in fixed locations, especially the rectum and anus, treatment is supplemented with a combination of radiation and chemotherapy.

“Treatment options are individualized based on the tumor size, location and stage of the cancer,” said Dr. Kathleen Schneekloth, radiation oncologist with Avera Medical Group Radiation Oncology.

“Radiation therapy can be used in concert with chemotherapy, pre- or post-operative, for early stage disease,” Dr. Schneekloth said. It can also play a palliative role if cancer has metastasized, or provide local control to slow the growth of cancer.

In the interest of patient education, Dr. Tolentino has co-authored a book, “Colon & Re c t a l C a n c e r Fro m Dia g n o s i s t o Tre a tment.” Eight chapters in length, the book provides an overview of colorectal cancer, and describes screening and diagnostic procedures, genetic testing, and staging of colorectal cancer. It covers various treatment modes including surger y, ch e m o therapy, radiation therapy and follow-up care. The book, which serves as a reference for patients, families, and referring physicians, is published by Addicus Books.

“In the rectum and anal canal, radiation therapy plus chemotherapy is often used,” said Dr. Barbara Schlager, radiation oncologist with Avera Medical Group Radiation Oncology. Radiation may be used in the upper colon when the affected segment of the colon is attached to the abdominal walls. It may also be used to treat residual disease after surgery.

The primary goal of radiation therapy is to decrease the local recurrence rate after surgery. Recurrence rates are reduced in half when this approach is used.

Radiation may also be used prior to surgery to shrink a tumor, making it more resectable and to help avoid a colostomy.

The Avera Medical Group offers two matched ARTISTE™ linear accelerators. “Our state-of-the-art linear accelerators provide for the most tailored and accurate dosing,” Dr. Schneekloth said. “In the treatment of colorectal cancer, our goals include survival benefits, local control, making surgery possible, and avoiding a colostomy.”

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Genetics and Molecular Testing Determines Hereditary Links to Colorectal Cancer Classifying colorectal cancer based on its molecular features is helpful to physicians in determining prognosis and treatment options. Genetic testing also helps patients and their family members take steps for early detection and prevention of colorectal cancer, preventing deaths, and the expense of advanced cancer treatment.

An estimated 5 to 10 percent of all colorectal cancers involve inherited genes.

Dr. Raed Sulaiman

“In earlier days, we classified tumors based on what we could see under the microscope,” said Dr. Raed Sulaiman, Avera McKennan pathologist. “With the advancements in molecular testing, we are able to classify tumors according to molecular structure when the situation warrants.”

When physicians suspect a possible genetic risk or link to cancer, they can refer patients to our certified genetic counselor, Nicole Mattila. Individuals or families might be referred for genetic counseling if they are diagnosed with cancer at an early age (less than 50), if they have a family member with colon cancer or other cancers found in hereditary syndromes, or if they have a polyposis syndrome, with 10 or more adenomatous polyps.

Counseling involves gathering a detailed family history, performing a risk assessment, and providing patient education about hereditary syndromes and genetic testing. If patients or families opt for genetic testing, it involves a simple blood test or swab check. Testing is always optional for those who have genetic counseling.

“I help individuals explore the pros, cons, benefits and limitations of genetic testing so they can make an informed decision,” Mattila said. Testing positive for a genetic syndrome may initiate increased surveillance or more extensive surgery to prevent recurrence.

The most common hereditary syndromes include Lynch syndrome, which increases the risk of colon and other cancers, and familial adenomatous polyposis (FAP), which results in the formation of hundreds or thousands of precancerous polyps at an early age.

Research has shown that patients and families carrying the gene mutations associated with Lynch syndrome (Hereditary NonPolyposis Colon Cancer – HNPCC) are at a significantly increased risk of developing not only colorectal cancer, but other cancers as well.

Because only 15 percent of CRCs can be classified as microsatellite instability (MSI), and of those, only 2-5 percent are inherited, only a portion of patients stand to benefit from MSI screening, Dr. Sulaiman said. To help identify these patients, Avera Digestive Disease Institute

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Nicole Mattila Genetic Counselor has adopted the Revised Bethesda Guidelines, set at the National Cancer Institute headquarters in Bethesda, Md. Dr. Sulaiman says approximately 20 percent of Avera colorectal cancer patients fit into these criteria.

Any patient meeting one of the listed criteria receives a screening test using IHC (immunohistochemistry) of the resection tumor sample. If results are abnormal, the patient is offered genetic counseling and further genetic

Revised Bethesda Guidelines: 1. Diagnosed with colorectal carcinoma (CRC) before the age of 50 years 2. Synchronous or metachronous CRC or other Lynch syndrome (HNPCC)-related tumors (stomach, bladder, ureter, renal pelvis, biliary tract, brain (glioblastoma), sebaceous gland adenomas, keratoacanthomas, and small bowel carcinoma, regardless of age 3. CRC with a high-microsatellite instability morphology (tumor infiltrating lymphocytes, Crohn’s-like reaction, mucinous/signet ring differentiation, or medullary growth pattern) that was diagnosed before the age of 60 years 4. CRC with one or more first-degree relative with CRC or other HNPCC-related tumors with one of the cancers being diagnosed under age 50 years (or adenoma under age 40 years)

tests as needed, although that comes at greater expense. A patient’s decision for further testing is based on their desire to have this knowledge and deal with the implications. “Not everyone wants to know,” Dr. Sulaiman added.

Dr. Sulaiman says other types of molecular screening are available for other types of cancer. Although molecular testing is beneficial, it is currently applicable in a small percentage. Yet Dr. Sulaiman expects this practice to grow with the advancement of medical science.

In the case of colorectal cancer, “identifying patients and families with conditions like Lynch syndrome allows appropriate medical management and preventative services to be in place to reduce hereditary cancer risk and improve outcomes,” Dr. Sulaiman added.

5. CRC with two or more relatives with CRC or other HNPCC-related tumors, regardless of age

“Most insurance companies are good about covering this testing, if patients meet family or personal guidelines,” Mattila said. People have protection under the federal Genetic Information Nondiscrimination Act (GINA) of 2008 in terms of health insurance coverage and employment.

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Clinical Trials are a Treatment Option with Cutting-Edge Drugs or Drug Combinations Participation in a clinical trial is one option for colorectal cancer patients. It can either be part of their recommended course of treatment, or be utilized after standard treatments have not been effective in slowing the course of the disease.

“Clinical trials give patients access to cutting edge treatments, often several years before they are available as an approved standard treatment,” said Dr. Addison Tolentino, medical oncologist and hematologist with Avera Medical Group Oncology & Hematology.

“At the time of diagnosis, we lay out all the options – both standard and alternative treatments – and decide what is best for the patient. We take into account the patient’s preference and the professional opinion of the physician,” Dr. Tolentino said. “Clinical trials may be one of those options.”

“Molecular treatment is the wave of the future. Future treatment will depend on what we know about the molecular makeup of the tumor, with targeted treatment based on that knowledge,” Dr. Tolentino said.

Through the Avera Research Institute, the Avera Cancer Institute offers clinical trials for patients at stage II, III and IV. Stage II studies are designed to determine which subgroups of patients benefit from chemotherapy. A stage III trial is studying the difference between a course of six and 12 chemotherapy treatments. Stage IV trials study the use of molecular agents in metastatic colorectal cancer.

Current Studies at Avera Digestive Disease Institute Study

Disease Site

Stage

Specifics

C80405

Colon/rectum

Mets or locally Wild K-Ras gene only advanced FOLFOX or FOLFIRI + Bevacizumab or Cetuximab

C80702

Colon Stage III

N1 or N2 = OK No residual involved lymph node disease or met. disease

6 vs 12 wks FOLFOX + Celebrex/ Placebo

E4203

Colorectal

Metastatic

Txmt assignment based on TS expression

N0949

Colorectal

Metastatic

1st line txmt - elderly

MCCRC RC0948

Colon – NO rectal

T3N0MX Stage II

OncotypeDX study

NSABP P-5

Colon

Stage I or II

Statin Polyp Prevention

C80701

Pancreatic

Metastatic or locally advanced

Everolimus alone or Everolimus + Bevacizumab

Advanced

Sorafenib + Doxorubicin vs Sorafenib

C80802

Hepatocellular

Must have evidence of disease with evidence of progression

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2012 Avera Cancer Institute Oncology Symposium Collaborative Cancer Care: Primary & Specialty Provider’s Role Through The Care Continuum Friday, September 21, 2012 • 8 a.m. - 5 p.m.

Saturday, September 22, 2012 • 8 a.m. - 2 p.m.

Goal: Avera Cancer Institute symposium is designed to enhance collaboration between primary and specialty providers in caring for individuals with cancer.

Audience: Physicians, physician assistants, nurse practitioners, nurses, social workers, pharmacists, dosimetrists, radiologic technologists, radiation therapists, chaplains, other interested health care professionals, patients, and community members.

To Register, Visit Avera.org/oncologysymposium or call 605-322-3000 w w w. Av e r a D i g e s t i v e D i s e a s e . o r g

Multidisciplinary Team Includes the Following Areas of Specialty: Colorectal Surgery: Scott L. Baker, MD, FACS

Gastroenterology and Hepatology:

Steven Condron, MD, MHES, FACP Cristina Hill Jensen, MD Christopher Hurley, MD Larry W. Schafer, MD, FACP Dany Shamoun, MD

General Surgery:

Scott L. Baker, MD, FACS Michael Bauer, MD Wade E. Dosch, MD, FACS David Flanagan, MD Thomas E. Fullerton, MD Michael Person, MD David A. Strand, MD, FACS Bradley C. Thaemert, MD, FACS Donald J. Wingert, MD, FACS

Genetics:

Nicole Mattila, CGC, MS

Medical Oncology: Mark R. Huber, MD Heidi McKean, MD Addison R. Tolentino, MD David Elson, MD

Pathology:

Steven P. Olson, MD Bruce R. Prouse, MD Raed A. Sulaiman, MD

Radiation Oncology: Barbara Schlager, MD Kathleen L. Schneekloth, MD

Radiology:

Sabina Choudhry, MD Brad A. Paulson, MD

Research

(Cancer clinical trials)

Urogynecology:

Matthew A. Barker, MD, FACOG

Hepatology and Transplant Surgery

Christopher Auvenshine, DO Hesham Elgouhari, MD, FACP Tariq N. Khan, MD Mumtaz Niazi, MD

If you have any questions or would like to make a referral to the Avera Digestive Disease Institute, call 605-322-7797. w w w. Av e r a D i g e s t i v e D i s e a s e . o r g

Go Online to Learn More!

To learn more, visit our website at www.AveraDigestiveDisease.org

1325 S. Cliff Avenue Sioux Falls, SD 57105

Hours: 8 a.m. - 5 p.m. • 605-322-7797 To learn more, visit our website at www.AveraDigestiveDisease.org