LaBahn Pancreatic Cancer Program's Purple Post: Volume 1 Issue 3

PURPLE POST

LaBahn Pancreatic Cancer Program Newsletter VOLUME 1, ISSUE 3 | FEBRUARY 2022

FOLLOW US ON: @MCWPancreasProgram @MCWPancreasProgram

Welcome

@MCWPancProgram

In this issue of the Purple Post, we are delighted to highlight the tremendous clinical care and innovative research efforts of our Radiation Oncology colleagues. Many may not know that the Department of Radiation Oncology at the Medical College of Wisconsin (MCW) is widely recognized as one of the very best, if not the best program, in the country. The MCW LaBahn Pancreatic Cancer Program is fortunate to work with several talented members of this department. In this issue, we invite you to come “behind the scenes” to learn more about the faculty and staff in the department and how their research is leading the way in radiation oncology.

The MCW LaBahn Pancreatic Cancer Program considers radiation therapy an important component in the treatment of localized pancreatic cancer. Our exceptional radiation oncologists, Drs. Beth Erickson and Bill Hall, each lead investigatorinitiated clinical trials which are examining different doses and delivery of radiation to patients with non-metastatic disease. We are fortunate to be one of a handful of centers in the country to have a magnetic resonance (MR) linear accelerator (LINAC). This machine allows for real-time imaging during treatment delivery and the ability to adapt the radiation plan to customize treatment daily. This facilitates the delivery of radiation specifically to the tumor and minimizes radiation to non-tumor areas.

In this issue, you will learn more about the clinical staff who work tirelessly behind the scenes to provide the best radiation therapy possible. In addition, you will get a glimpse into the “ART” of radiation oncology, which uses novel scientific processes to further customize and personalize radiation therapies for each patient. In our patient feature, you will meet Bill Whitney, who is a 10 year + survivor of pancreatic cancer! Finally, we are delighted to share that Dr. Beth Erickson received the J. Frank and Vera B. Wilson Professorship in Radiation Oncology. This is a tremendous honor for a truly deserving and gifted physician.

Sincerely, Susan Tsai, MD, MHS Director, LaBahn Pancreatic Cancer Program

Purple Post The Purple Post Newsletter is a publication by the LaBahn Pancreatic Cancer Program to provide patients, family, and loved ones with informative and current topics at the Medical College of Wisconsin. Issue are published every February, June, and October.

Art + Production Lori Keiser, BS, MA Melissa Mena, BS, CCRC

Editing Beth Krzywda, APNP

LaBahn Pancreatic Cancer Program Director Susan Tsai, MD, MHS

LaBahn Pancreatic Cancer Program 8701 W Watertown Plank Rd Wauwatosa, WI 53226 mcwpancreas@mcw.edu © Copyright 2022 LaBahn Pancreatic Cancer Program All rights reserved. No part of this publication may be reproduced by any means, prints, electronic, or any other, without prior written permission of the publisher.

For questions, comments, or to submit an idea for an upcoming newsletter, please contact us at mcwpancreas@mcw.edu or 414-955-1423.

Left- Original medical linear accelerator, developed by Dr. Henry Kaplan of Stanford University. Image credit: Stanford University.

Right- In 2019, physicians at Froedtert & Medical College of Wisconsin treated their first patient on the Elekta Unity MR-Linac.

This radiation therapy technology combines MRI scanner with a linear accelerator. Image credit: Froedtert & Medical College of Wisconsin

Studying Different Types of Radiation Therapy, SBRT and Fractionated Radiation, An Example of Team Science Article by: William Hall, MD

R

adiation therapy is a cancer treatment involving invisible, high-energy xray’s that are focused by a large machine into an area of the body where a cancerous tumor is located. The goal of these x-rays is to kill cancer cells.

Radiation therapy has been used for over a century to treat, and cure, many different types of cancer. Over that time, radiation has dramatically changed. Most of the change has been the result of advances in technology, specifically medical imaging and new computers. These advances have resulted in a wide range of different strategies that can be used to deliver radiation. Today, there are many ways that radiation therapy can be given for patients with pancreatic cancer. In the past, patients with pancreatic cancer were often treated over multiple daily treatments, sometimes lasting five to six weeks. More recently radiation oncologists have been attempting to shorten this treatment course by giving higher doses of radiation therapy over a shorter period. This has multiple potential benefits including less time in the hospital, less inconvenience for patients, and potentially lower costs. However, it is unknown if this quicker and more convenient treatment will result in similar outcomes to a longer treatment course. The goal of our current research is to robustly answer this question. We designed the SOFT clinical trial to compare a longer treatment course (5 to 6 weeks of daily radiation treatment), with a shorter treatment course (a total of 5 days). The study randomly assigns patients to either five total treatments or 28 total treatments, all given before surgery. This study also gives us the chance to very carefully compare patient tolerance between these different types of radiation treatments. From this study we are learning a tremendous amount about the way that pancreatic tumors respond to these different types of radiation therapy. Patients have generously contributed their time to complete multiple questionnaires about their symptoms and quality of life during these treatments. Data that is generated from this study will allow doctors to understand how these two different forms of radiation impact patients. The pancreatic research team meets weekly to discuss the outcomes of patients who have been enrolled in this clinical trial. Surgeons and radiation oncologists can discuss findings that are seen at the time of operations, and translational research experts are studying how the immune system is impacted by these treatments. This will ultimately enable us to better understand which of these treatments is better and ideally improve the ability to cure patients with pancreatic cancer.

Unsung Heroes of Radiation Oncology Learn about members of your Radiation Oncology team. Some you'll see daily, while others work behind the scenes!

D O S I M E T R I S T S A medical dosimetrist uses computer software to generate a radiation treatment plan that delivers a therapeutic dose of radiation to a tumor while minimizing the radiation delivered to healthy tissues. To accomplish this, a CT scan is obtained of the patient which provides a 3D representation of the patient's anatomy. The dosimetrist imports this CT scan into the treatment planning computer and uses it to determine the optimal radiation beam angles, energies, and shapes for treatment delivery based on the prescription provided by the radiation oncologist. Depending on the complexity of the case, creating a treatment plan can take anywhere from 15 minutes to several days. Critical thinking and problem solving skills allow the dosimetrist to meet each patient's needs. They collaborate closely with the radiation oncologist regarding the tumor dose prescription, dose limits to healthy tissues, and final approval of the treatment plan. Left- Dosimetrist at Froedtert & MCW Dana Koller.

R A D I A T I O N

T H E R A P I S T S

Radiation Therapists are responsible for delivering safe and effective radiation treatments to patients. They are highly skilled with a four year degree in radiation therapy. This role provides a unique opportunity to build relationships with patients. The day-to-day responsibilities include: imaging patients, positioning patients for treatment, documenting treatment delivered, patient education, and responding to patient needs. Radiation therapists work very closely with all other team members in Radiation Oncology. They coordinate with nurses and medical assistants on patient education, communicate with dosimetrists for changes to treatment plans, and work with physicians to ensure proper delivery of the treatment plan. Sarah Macdonald (top) and Britta Nelson (bottom), Lead Radiation Therapists at Froedtert & MCW.

M E D I C A L

P H Y S I C I S T S

Medical Physicists are responsible for developing and directing quality control programs for the equipment and treatment procedures being delivered to patients. They take precise measurements of the radiation beam to make sure equipment is maintaining tight performance tolerances. Another important role is to oversee the work of the dosimetrist to ensure each treatment plan has been properly tailored to each patient's case. They work closely with IT and engineering staff to ensure all equipment and computers are working correctly. Many dedicate time to research focusing on improving imaging techniques and new therapeutic techniques through the application of physics concepts. They collaborate with many of the radiation oncology team members. For example, they work with the radiation oncologist to design treatment plans and verify the calculations completed by the dosimetrists. In complex cases, the medical physicist may be present and help deliver the treatment. Like dosimetrists, the medical physicist works primarily behind the scenes to carry out their role, but are essential to the safe and effective delivery of radiation therapy. Above- MCW Medical Physicist, Eric Paulson, PhD.

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RESEARCH PRESENTED AT NATIONAL CONFERENCES Medical College of Wisconsin faculty, residents, and post-docs in the Department of Radiation Oncology presented their cutting-edge research towards improving the accuracy and efficiency of radiation treatment for pancreatic cancer at the 2021 annual meetings of the American Society for Radiation Oncology (ASTRO) and the American Association of Physicists in Medicine (AAPM), the two major scientific meetings in the field of radiation oncology.

Haidy Nasief, PhD, a radiation oncology medical physics resident, presented a study at the AAPM meeting on predicting treatment response for pancreatic cancer patients using the texture features extracted from daily MRIs acquired on a MRILinac during MR-guided adaptive radiation therapy (MRgART).

This technology is an emerging and promising treatment technique. Traditionally, medical images are used as pictures of a patient’s internal anatomy for disease diagnosis and prognosis. This work converted medical images into quantitative data using a computer program and built an artificial intelligence model to predict and early treatment response.

OTHER RADIATION ONCOLOGY PRESENTERS AT THE 2021 NATIONAL CONFERENCES

Potential benefits include improved treatment plan selection for precision medicine and personalized radiation therapy. Dr. Nasief also studied the use of measurable image features to predict the need for adaptive replanning leading to better outcomes for pancreatic cancer patients. The work was presented at the ASTRO meeting and received the Basic-Translational Science Abstract Award.

Ying Zhang, PhD, a radiation oncology medical physics resident, presented a unique automatic contour quality assurance method at the ASTRO meeting. This significant research received the Basic-Translational Science Abstract Award at the meeting. Contouring is the act of defining the borders of a patient’s tumor and normal organs. It optimizes the treatment plan using the daily MRI to better treat the tumors and spare surrounding healthy organs. The efficiency of contouring is important because patients wait on the table for treatment. This work developed an automatic contour quality checking system to replace the time-consuming manual organ contour checking process in current workflow. The clinicians only need edit the flagged contours, which can improve the efficiency and reduce waiting time for the patient.

Another new interactive contouring method was also developed by Dr. Zhang and presented at the AAPM meeting. It uses contours on an adjacent image as prior knowledge to inform the automation of contouring a subsequent image. This method can accelerate the contouring process and facilitating the more routine practice of MRgART for pancreatic cancer.

DID YOU KNOW?

Dr. Asma Amjad Resident

Dr. Xinfeng Chen Instructor

Dr. Xioajian Chen Assistant Professor

Dr. Garrett Godfrey Post-doc Fellow

Dr. George Noid Instructor

Dr. Eenas Omari Assistant Professor

In 2021, nearly 40% of physics research at MCW focused on pancreatic cancer.

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Scientific Investigator Highlight Medical Physics Research in Pancreatic Cancer

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ach quarter, the Purple Post features a scientific investigator at MCW that is directly contributing to pancreatic cancer research. This quarter, we are featuring the work of Dr. Allen Li and his team of medical physicists. Part of a medical physicist's job at MCW is researching to improve imaging techniques and develop new ones. Dr. Li and team are pioneers in the development of Adaptive Radiation Therapy, or ART. This new model of radiation therapy specifically accounts for the changes in location, shape, and size of the tumor and surrounding tissues both during a single treatment session as well as between treatment sessions. The overall goal of radiation therapy is to deliver radiation to the tumor while minimizing radiation to surrounding normal tissues. Adaptive Radiation Therapy is one way the team here at MCW is furthering that goal. Highlighted below, are further examples of the work being done by Dr. Li and his team.

Allen Li, PhD, FAAPM Professor & Section Chief of Medical Physics

Dr. Beth Erickson, MD, professor of radiation oncology, has been awarded the J. Frank and Vera B. Wilson Professorship in Radiation Oncology

Eric Paulson, PhD, Associate Professor

Ergun Ahunbay, PhD Associate Professor

An Tai, PhD Associate Professor

George Noid, PhD, Instructor

Dr. Allen Li lead’s the group’s efforts to develop techniques and strategies to improve adaptive radiation therapy for pancreatic cancer. These efforts include: 1) accelerating image segmentation (the process of dividing images into different meaningful segments such as organs) and treatment optimization, thereby improving the efficiency of ART process, and 2) investigating imaging biomarkers for early detection of treatment response, thus, enabling response-based treatment adaptation Dr. Eric Paulson has developed innovative MRI acquisition and processing methods to improve detection of organ motion and outlining of tumors and normal structures. Dr. Paulson’s original four-dimensional MRI technique positioned Froedtert & MCW to be among the first institutions in the world to offer motion-incorporated MRI guided ART for pancreatic cancer.

Dr. Ergun Ahunbay is a recognized expert in the treatment planning algorithms for ART and has developed a new algorithm that has been implemented for ART planning. He is working on a new technique to identify air quickly and automatically on MRI imaging, increasing the accuracy of radiation does calculation during ART for pancreatic cancer.

Effective management of the complex abdominal motion during treatment is essential during the delivery of high precision radiation therapy for pancreatic cancer. Dr. An Tai is leading a team investigating the motion of different abdominal organs and has developed and implemented practical strategies to manage the motion using real-time image guidance.

Dr. Erickson joined the MCW faculty in 1989 as an assistant professor of radiation oncology, was promoted to associate professor in 1996 and professor in 2001. She received a secondary appointment in the Department of Surgery in 2018. Her clinical practice focuses on the treatment of patients with gastrointestinal, gynecologic, and eye/orbital cancers. She also serves as Chief of Brachytherapy Services.

Dr. Erickson is interested in image-based treatment planning, for both external-beam and brachytherapy. She has been recognized by numerous organization and media outlets as a top scientist in her field. Dr. Erickson is a peer reviewer for more than a dozen scholarly publications and serves as the editor of the gynecology section of Journal of Brachytherapy International and on its editorial board.

Additionally, she has provided national and international service in leadership roles with professional societies.

Furthermore, she has been invited to speak at many local, regional, national, and international events. Lastly, Dr. Erickson has authored or co-authored more than 250 peerreviewed articles. The J. Frank and Vera B. Wilson Professorship in Radiation Oncology has been awarded to Dr. Erickson as she embodies the Wilson's remarkable vision and unwavering commitment and enables the support of education, research, and excellence in patient care which in turn has had a dramatic positive ripple effect on the community.

Accurately distinguishing the tumor from normal tissue and organs is vital for precision radiation therapy and often requires multi-modality images. Dr. George Noid is working collaboratively with Siemens (a medical device company) to develop new applications for using simultaneous dual-source dual-energy CT scans to provide additional information for the outlining of pancreatic tumors. He is also investigating the use of dual-energy CT to detect early treatment response during radiation therapy for pancreatic cancer.

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A Family Affair in Pancreatic Cancer Research Article by: David Wittmann, Third-Year Medical Student

David Wittman, MCW M3, is joined by his parents Drs. Beth Erickson Wittman and Thomas Wittman at the 2021 ASTRO meeting

Growing up in a household with physician parents, I quickly learned the demands of a career in medicine. I saw a unique opportunity to have a meaningful impact on patients’ lives, so I decided to apply to medical school so that I could one day provide the same care to future patients. My mom, Beth Erickson, Professor of Radiation Oncology and Surgical Oncology, has been a role model of mine since I am interested in pursuing a career in Radiation Oncology. Expanding on this interest, I have been fortunate to be involved in various radiation therapy research projects during the early years of my medical education. Below is a summary of these projects and my invovlement in them.

In 2018-2019, the year prior starting medical school, I had the opportunity to conduct research with Dr. Susan Tsai, Professor of Surgery and Director of the LaBahn Pancreatic Cancer Program. We were interested in studying the role of neoadjuvant chemoradiation in patients undergoing treatment for pancreatic cancer. Previous studies have shown a survival benefit in patients who received neoadjuvant chemoradiation and achieved a complete pathologic response, meaning the cancerous tissue was effectively treated by the preceding chemotherapy and radiation therapy. However, it was uncertain whether optimal neoadjuvant therapy should include chemotherapy, chemoradiation, or both.

Through our statistical analyses, we determined that chemoradiation is associated with improved tissue response compared to chemotherapy alone. More importantly, there is a tremendous improvement in nodal status, or lymph nodes which the cancer spreads to, in patients receiving chemoradiation. This improved nodal status is associated with significant survival benefit in our pancreatic cancer patients who receive chemoradiation.

David Wittmann is pictured here with his mother, Dr. Beth EricksonWittmman following his presentation at the 2021 ASTRO meeting in Chicago, IL

Beginning in 2019, I have been working with Dr. William Hall, Associate Professor of Radiation Oncology and Surgery. Dr. Hall and I are interested in abdominal organ (stomach, small bowel, colon, etc.) movement in patients treated on the MR-Linac, one of the devices which delivers radiation to patients. At baseline, many of our abdominal organs move when we breathe or due to peristalsis. However, this poses a challenge when delivering precise radiation therapy because to safely do so, we need to create a plan by identifying the radiation targets and safely exclude the nearby organs. This adaptive planning process can take from 15-60 minutes. During this planning time, these organs can move into the radiation dose distribution which Figure 1 would compromise their safety (see Figure 1).

Left: Pre-verification MRI. The radiation dose is indicated by the concentric rings, the duodenum is outline in yellow, the small bowel is outline in teal, and the colon is outlined in purple.

Right: Verification MRI, note the yellow arrow showing the small bowel moving into the radiation dose distribution during the time required to modify the radiation plan. Had this image not been acquired, we would not have been able to adjust the radiation plan to avoid radiation delivery to the small bowel. This emphasizes the importance of acquiring a verification image prior to starting radiation treatment delivery.

After conducting several statistical analyses, we found that highly mobile organs, particularly the small bowel, exhibit significant motion which translates into the potential for exposure to unnecessary radiation. In order to account for this, we strongly emphasize the importance of acquiring another image, called the “verification image”, immediately prior to starting the radiation treatment in order to verify that these organs will remain safe during the radiation delivery.

In October of 2021, I presented my research at the American Society for Radiation Oncology (ASTRO) in an oral presentation entitled "Quantification and Dosimetric Impact of Normal Organ Motion during Adaptive Radiation Therapy Plan Verification using 1.5 Tesla Magnetic Resonance Equipped Linear Accelerator (MRLinac).

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PATIENT FEATURE: MEET WILLIAM WHITNEY In 2010 William (Bill) Whitney, age 74, developed persistent back pain. After a visit to his doctor, they found the source of his pain, a malignant pancreas tumor. Because his tumor encased a major artery, surgery was not recommended and his cancer treatment began with chemotherapy. In addition, he was referred to Dr. Beth Erickson, a radiation oncologist, for consideration of radiation therapy as part of his treatment. He was thought to be an excellent candidate for a new treatment option, dose-escalated radiation. Under the care of Dr. Erickson his radiation would be completed with both CT and MR imaging to best define his tumor. This would allow the highest dose of radiation to treat his tumor while carefully limiting radiation to his surrounding organs. Little did Bill or Dr. Erickson know, this would be the start of the MR-guided dose escalation program, which has since grown to treat many other patients diagnosed with inoperable pancreatic cancer.

Bill went through six weeks of radiation treatment, receiving chemotherapy with the radiation. Shortly after radiation was completed, Bill had some enlarging lymph nodes, and additional chemotherapy was recommended under the care of Dr. George, medical oncologist.

Eventually the lymph nodes were surgically removed and found to be negative for cancer. After completing his treatment in 2011, Bill did well without any evidence of pancreatic cancer until 2017 when he developed new lung nodules concerning for recurrent cancer. These were treated with Stereotactic Body Radiation Therapy (SBRT) in 2018 and surgery in 2021. Since then, Bill's scans have been clear, showing no signs of cancer.

Throughout the years, Bill enjoyed traveling, golfing, and spending time with his family boating on the lake near his home, much to the jubilation of his wonderful wife Mary, his children, and grandchildren.

Dose Escalation At The Medical College of Wisconsin The ability to control pancreatic cancer with dose-escalated radiation in patients like Bill, has been motivation for the radiation oncology team at MCW to continue evolving and perfecting this approach. MCW is one of the first facilities in the country to use radiation therapy technology that has a built in MRI scanner, allowing them to adapt the radiation plan each time the patient is here for treatment. Research evaluating the delivery of increasingly higher doses of radiation using MR guidance has nearly been completed for patients with unresectable pancreas cancer at MCW. Patients inspire and motivate the physicians who are blessed to work with them, and this in turn helps other patients. This is truly the case with Bill Whitney.

LaBahn Pancreatic Cancer Team Spotlight What is your role at MCW and how long have you been a part of the team?

I have been an oncology nurse for 20 years and a Nurse Practitioner at MCW in Radiation Oncology for 13 of those years. I have been working with pancreatic cancer patients since I joined MCW as a new Nurse Practitioner in 2009.

Susan Thoreson, MS, FNP-BC, APNP, OCN

What are some of your interests and hobbies outside of work?

I have two busy girls, ages 8 and 11. Most of my free time is spent with my husband and my girls. I am passionate about animals and we have two dogs and one cat. We enjoy being outdoors walking our dogs or going to the zoo. I also enjoy baking and decorating cakes.

What do you enjoy most about the work that you do?

I enjoy the privilege of being able to enter patients' lives at what is often a frightening and difficult time. Working in radiation oncology has allowed me to help support patients physically and emotionally through what is often a long course of daily treatments. We truly get to know our patients and their families. I find nothing more rewarding than seeing our patients back in long term follow up, doing well, and living life.

FAVORITE QUOTE

Radiation Oncology Nurse Practitioner

"Yesterday's the past, tomorrow's the future, but today is a gift. That's why it's called the present."

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SAVE THE DATE: SATURDAY, APRIL 30, 2022 PurpleStride Milwaukee

PURPLE POST LaBahn Pancreatic Cancer Program Newsletter

Check out pancan.org or the MilwaukeePancreatic Cancer Action Network Facebook page for details.

LaBahn Pancreatic Cancer Program Medical College of Wisconsin Division of Surgical Oncology 8701 Watertown Plank Rd. Milwaukee, WI 53226