care ER
for anyone touched by cancer FALL 2015
Helping others, helping himself
s
CAN
page 5
Removing a kidney tumor from a toddler page 9
What you can learn from the ‘relief team’ page 10 Why pain control matters page 12
How prostate cancer is staged, graded page 13
Brought to you by the
Most prevalent cancers at Upstate
YOUR GUIDE
Prostate, breast, thyroid and lung cancers are the most commonly diagnosed cancers in New York state, outside of New York City. They are also the top diagnoses among cancer patients being treated at Upstate University Hospital.
THYROID/ ENDOCRINE
PROSTATE
BRAIN/ NERVOUS SYSTEM
COLORECTAL
KIDNEY
BLADDER/URINARY ORGANS
HODGKIN’S/NON-HODGKIN LYMPHOMA
PANCREAS
17.7% 16.94% 8.02%
7.52%
5.36
5.32
4.59
4.01
3.88
2.75
BREAST
18% 16% 14% 12% 10% 8% 6% 4% 2%
LUNG/RESPIRATORY ORGANS
Neurological, kidney and bladder cancers affect far fewer Upstate New Yorkers. Yet, many people with these cancers seek care at Upstate because of its strong reputation.
Smoke-free policy cleared the air, set standards, improved health The top 10 cancer diagnoses, by percentage, of adult patients treated at Upstate in one year. Source: Upstate University Hospital
Upstate University Hospital was the first health care facility in New York state to kick the smoking habit by banning cigarettes in 2005. The campus was also the first within the State University of New York system to become entirely smoke-free. Other hospitals and medical offices, colleges and universities followed the Upstate example.
In 2009, the Onondaga County Legislature enacted a law prohibiting smoking within 100 feet of the perimeter of property operating as a general hospital. And in 2012, Upstate strengthened its stance and became entirely tobacco-free, outlawing electronic cigarettes and other forms of tobacco. The goal all along was to illustrate Upstate’s health care mission as well as clear the air of secondhand smoke
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exposure for staff, students, patients and visitors — and thus reduce the risk of cancer. At the same time, a Smoking Cessation Program was implemented, and is still in operation today, for Upstate employees and the Central New York community. (Find out more by calling 315-464-8668.) This and other efforts helped Upstate earn CEO Gold Standard accreditation. This is an award from a nonprofit organization of chief executive officers called the CEO Roundtable on Cancer, founded by former President George H.W. Bush in collaboration with the National Cancer Institute. The Gold Standard calls for workplaces to evaluate their health benefits and corporate culture and take concrete actions to reduce the risk of cancer in the workplace. ●
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INSIDE
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Inside this issue CARING FOR PATIENTS Humor, acceptance helped her heal
page 4
A survivor delivers hope
page 5
Why some cancer programs undergo accreditation
page 7
Surgery, chemo help remove preschooler’s kidney tumor
page 9
Relief team offers palliative care UpClose look at Upstate’s bone marrow transplant program
SHARING EXPERTISE
page 10
back cover
Most prevalent cancers
page 2 page 12
Why pain relief matters
page 12
How prostate cancer is staged and graded
page 13
SEARCHING FOR CURES Will zinc be an element of future cancer treatment?
page 14
A new way to deliver cancer drugs
page 15
More veggies, less starch
page 16
10 commandments from the Cancer Patient’s Workbook
page 16
LIVING WITH CANCER
MAKING A DIFFERENCE Smoke-free for 10 years
page 2
These docs pal around with pediatric patients
page 17
A match made in marrow
page 18
Adding comfort to a hospital stay
page 19
On the cover: Jack Edgerton volunteers at the Upstate Cancer Center after receiving his cancer care through Upstate.
care
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by can cer
Helping others helpin , himselfg page FAL L
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The role of an oncology dietitian
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PHOTO BY SUSAN KAHN
care
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FALL 2015
CANCER CARE PUBLISHER Wanda Thompson, PhD Senior Vice President for Operations EXECUTIVE EDITOR Leah Caldwell Assistant Vice President, Marketing & University Communications MANAGING EDITOR
Amber Smith 315-464-4822 or smithamb@upstate.edu
DESIGNER
Brought to you
by the
ER
for anyone touched by cancer
WRITERS
5 Removin ga kidney tumor from a toddler page 9 What you can lear from the ‘relief teamn ’ page 10 Why pain control matters page 12 How pros tate is staged, cancer graded page 13
Jim Howe, Amber Smith Susan Keeter
The Upstate Cancer Center provides the quarterly magazine, Cancer Care, for anyone touched by cancer. Send subscription requests and suggestions to magazine@upstate.edu and request additional copies by calling 315-464-4836. Cancer Care offices are located at 250 Harrison St., Syracuse, NY 13202.
UPSTATE CANCER CENTER MEDICAL DIRECTOR Leslie J. Kohman, MD
The Upstate Cancer Center is part of Upstate Medical University in Syracuse, NY, one of 64 institutions that make up the State University of New York, the largest comprehensive university system in the United States. For information on cancer center patient services, call 315-464-HOPE (4673) or visit www.upstate.edu/cancer. The Cancer Center is located at 750 E. Adams St., Syracuse, NY 13210. Upstate Medical University is an academic medical center with four colleges, a robust biomedical research enterprise and an extensive clinical health care system that includes Upstate University Hospital’s downtown and community campuses, the Upstate Golisano Children’s Hospital, and many outpatient facilities throughout Central New York — in addition to the Upstate Cancer Center.
ASSOCIATE ADMINISTRATOR Richard J. Kilburg, MBA
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CARING FOR PATIENTS
Save the Date
LUNG CANCER AWARENESS: EXPAND YOUR LUNGS & YOUR MIND
Thursday, Nov. 19 All day Great American Smokeout
2 to 5 p.m. Cancer in the Crosshairs Speakers on topics in medical oncology and radiation oncology
5 p.m. Lung Cancer Vigil
Patty Agne said she was fortunate to have the support and advice of her sister, Susan Byrns, and Byrns’ daughter, Malinda Seymour, who are both oncology nurses. “I had this guidance all the way through,” said Agne, who plans to volunteer at the Upstate Cancer Center.
Healing helpers:
humor, acceptance, positive attitude BY JIM HOWE
As Patty Agne navigated the pain, uncertainty and odd moments of her experience with breast cancer, she found that her attitude was key. Her attitude helped her: l
5:30 to 6 p.m. Reception Cancer Center Atrium
6 to 7 p.m. Art tours Cancer Center UPSTATE.EDU/SPECIALEVENTS
PHOTO BY ROBERT MESCAVAGE
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keep a sense of humor. When her hair was falling out, she went with a friend to Saving Face Barbershop in Syracuse for a towel shave, and took selfies at every stage, including with her doctors. go with the flow. As a person who prefers “natural” things, she had to tolerate the “unnatural”: chemotherapy drugs. accept the necessary “healing sabbatical” she took for 8½ months during her treatment. This meant setting aside the work she loves as a self-employed massage therapist.
Agne, 60, of Syracuse, spoke to fellow survivors in June at a National Cancer Survivors’ Day event in the Syracuse area, sponsored by Upstate. She told about her father and brother, both of whom died of esophageal cancer, and about her 20 years as a massage therapist, which introduced her to cancer patients and survivors. She also spoke about humor while wearing — as did several people at the event — a silly balloon hat. “This stuff is not funny to most people, but I can find the humor, and that keeps me going,” said Agne. She likes to tell about a clueless health insurance worker who told her that breast cancer payments are made in a “lump” sum. “I’ve gotten a lot of mileage from that one.” Although some people consider her a control freak, Agne said, she decided to let Continued on page 8
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CARING FOR PATIENTS
Hope delivered by a survivor BY AMBER SMITH
The woman’s husband drove her to her cancer treatment until his boss told him he could not miss so much work. So her son started driving her. His grades suffered because he was missing so much school. Sitting in the waiting room one day, the young man shared his situation with Jack Edgerton, a volunteer in the Upstate Cancer Center. Edgerton helped connect the family with an American Cancer Society program that provides transportation. He was pleased he could help. The truth is, as much as Edgerton helps others, they also are helping him. It was Edgerton’s internal medicine doctor, Vincent Frechette, MD, who encouraged him to become a volunteer at the cancer center. “I think it would be good for you,” he told Edgerton.
continued on page 6
PHOTO BY SUSAN KAHN
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Jack Edgerton of Manlius has a booth at the Central New York Regional Market. Look for him near the middle of the shed marked “A,” selling honey and other products. PHOTO BY DEBBIE REXINE
He’s a survivor delivering hope continued from page 5 Edgerton, 72 and new to retirement, agreed that he did not want to sit home watching television, feeling unproductive. He wanted to interact with others, and he was comfortable in a medical setting. Edgerton always wanted to be a doctor, but he transferred from pre-med to business in college when he learned he was color-blind. He wound up running the family import business and ad agency for 52 years. Today, his volunteer position at the cancer center allows him to spend time with patients and their loved ones two days a week. When they learn that he’s a cancer survivor, “they just open up,” he said. “I can sympathize and empathize.” Edgerton underwent surgery for thyroid cancer in 2007. He had surgery again three years later to treat prostate cancer. He’s an example of a cancer survivor giving back. He readily shares details of his experiences with people at the cancer center. He jokes that he’s Irish, so he’s got the gift of gab. Edgerton wants to give people hope — hope that they, too, can get through treatment — which is why he’s so generous with his time. ●
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Building credibility
CARING FOR PATIENTS
Why some cancer programs open themselves up to assessment Patients and their loved ones may not realize why health care providers make an effort to earn various accreditations, or endorsements from outside organizations. They may notice an emblem on a web page or a trophy in a case without understanding its meaning. About 24 different agencies regularly review patient care services at Upstate University Hospital. For example, the American College of Surgeons’ Commission on Cancer awarded the Upstate Cancer Center a three-year accreditation in June. This is the fourth consecutive time Upstate’s cancer services have earned that accreditation. Each time the commission sent one of its physicians to conduct a review at Upstate, the physician gave multiple commendations and never once found a deficiency. That is something of which to be proud, says Anthony Weiss, MD, chief medical officer for Upstate University Hospital. “This represents over a decade of outstanding work and collaboration by the Upstate cancer team and is a testament to the hardworking individuals who serve our patients each day.”
The visiting physician evaluates compliance with 34 standards in areas including nursing care, clinical trial access, public reports and data submission and accuracy. Hospital administrators monitor clinical practices but appreciate input from a knowledgeable outsider — a third party who gives a neutral assessment in a review that, hopefully, leads to accreditation. What does that accreditation mean for cancer patients? “It means that the hospital is more informed about cancer and its treatment, as well as appropriate resources. It can offer more consistent and better quality care to its patients,” American Cancer Society Vice President Katherine Sharpe explains on the society website. “Getting treatment at an accredited facility can strengthen your confidence in the quality and safety of your care, treatment and services. This can lead to better outcomes and improved quality of life for patients.” More than 1,500 cancer programs in the United States and Puerto Rico have accreditation from the Commission on Cancer, and the commission estimates those programs treat nearly 70 percent of patients who are newly diagnosed each year. Upstate is the only accredited cancer program in the Syracuse area. ●
BRAIN EXPERTS REGION’S FIRST & ONLY COMPREHENSIVE STROKE CENTER
Upstate welcomes neurologist Hesham Masoud, MBBCh, and neurosurgeon Grahame Gould, MD, to the team of experts who provide round-the-clock stroke care at Upstate. They join neuroradiologist Amar Swarnkar, MD, (center) in offering stroke patients their expertise in the swift removal of brain clots, which greatly improves the patients’ odds of survival and recovery.
IF YOU SEE SIGNS OF A STROKE, ACT FAST.* CALL 911. TO LEARN MORE, CALL UPSTATE CONNECT AT 800.464.8668 OR VISIT WWW.UPSTATE.EDU/STROKE *Face, Arm, Speech, Time
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Patty Agne’s father and brother both died of esophageal cancer, and she learned about cancer survival from some of her massage therapy clients. PHOTO BY ROBERT MESCAVAGE
Humor, acceptance, positive attitude helped her heal continued from page 4
go and trust the process after she found a lump in her left breast in October 2013. That led to a diagnosis of breast cancer, with surgery the following summer. She underwent a second surgery on Aug. 1, 2014, and Kristine Keeney, MD, reported “negative lymph node and widely clear margins.” Cancer gone.
Keeney, the surgeon who removed the lump from Agne’s breast, said she remembers the massage therapist as “indomitable.”
Because of a high risk of recurrence, Agne had an intravenous port inserted, and she became one of the first patients to undergo chemotherapy in the new Upstate Cancer Center. After 16 chemotherapy treatments and a two-week break, she had radiation treatments five days a week for eight weeks. She will also take a daily pill for at least five years.
“She just came with an attitude that was strongwilled and upbeat,” Keeney said. “She is a Kristine Keeney, MD Anna Shapiro, MD healer, as well, and it was very important for both of us that she have successful surgery and treatment that would allow her to get back to her work that she so enjoys. She loves her work, is surrounded by great friends, and she uses her experience as a cancer patient to help her and others heal.”
How did she get through her treatment? “I have great faith, and I don’t mean about ‘going to church’ faith. I mean about deep trust in life and everything that happens,” Agne explained. “It’s an easier way to go through it, when I trust that I’m where I’m supposed to be. “Even Dr. Shapiro said that people do better with a positive attitude,” she said, quoting her radiation oncologist, Anna Shapiro, MD.
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Agne finished treatment in March and began seeing clients again in April. ●
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An intricate operation
CARING FOR PATIENTS
Surgery, chemo battle preschooler’s kidney tumor BY AMBER SMITH
Three-year-old Ariana LaVaute attended the Skaneateles Labor Day parade on Sept. 1, 2014, and then helped her father trim shrubs in their yard. A few days later, her activity level and appetite diminished. Seemingly overnight, her belly became enlarged. Ariana’s pediatrician immediately sent her to the Upstate Golisano Children’s Hospital. It was the day before she was scheduled to meet her preschool teacher. Rapidly growing in Ariana’s abdomen was a Wilms’ tumor, a cancer that began in one of her kidneys and grew to the size of a melon, invading her pelvis and growing into her heart. “Once they start growing, they tend to present as fairly large masses,” said Gloria Kennedy, MD, Ariana’s oncologist. Wilms’ tumors can start dividing in utero, often becoming quite large before they are noticed. Kennedy explained that a child with Wilms’ tumor is considered cured after he or she is free of malignancy for as many years as their age at diagnosis, plus 9 months to account for gestation. An initial surgery was done on Sept. 5, in an attempt to remove the mass. Doctors installed a port so that Ariana’s chemotherapy could begin the next day, with hopes of shrinking the tumor. In the months that followed, medication reduced the tumor size but not its extent, making a surgery that is challenging that much more complex. The final surgery was Jan. 21. Pediatric surgeon Tamer Ahmed, MD, said the tumor had grown into the vena cava, the vein that carries blood to the heart. To remove the tumor, not only would he have to remove her kidney, “we had the added complexity of having to open up that vein.”
Ariana’s pediatric team: oncologist Gloria Kennedy, MD; surgeon Tamer Ahmed, MD and cardiac surgeon George Alfieris, MD.
It was a big operation, lasting five or six hours and making use of the heart-lung machine so that Ariana’s heart would lay still while Ahmed and pediatric cardiac surgeon George Alfieris, MD, operated together. “It was a delicate operation,” Ahmed recalled, “but I think she did very well.” She has undergone eight months of chemotherapy and radiation treatments, which continued after the surgery. She has been hospitalized for nearly 30 days in total. Through it all, Ariana’s father, Jeff LaVaute, said she stayed strong. “Her bravery was, has been and continues to be positively inspirational,” he said. It was April 27 when he received a phone call about Ariana’s post-treatment scans. They showed she was cancer free and finally on the road to recovery. Since then, Ariana completed the last few weeks of preschool, which included her fourth birthday celebration on the Judge Ben Wiles boat. She and her family enjoyed a seven-day Make-a-Wish trip to Disney World. And this fall, a year after her diagnosis, Ariana started Bumblebee Soccer. ●
Ariana PHOTO COURTESY OF THE LAVAUTE FAMILY
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The relief team
CARING FOR PATIENTS
How palliative care brings comfort to suffering patients, families BY JIM HOWE
A doctor hangs her head. A patient loses hope. Medicines haven’t worked. Surgery is not an option. Frustration, fright, even anger fills the air.
months at home, and the palliative care team works to help achieve those goals, which will likely change during the course of the illness.
That’s often the type of situation nurse practitioner Susan Shaw encounters.
New York state requires health care providers to give patients with a terminal illness information and counseling about palliative care and end-of-life options. Two doctors and three nurse practitioners make up the Adult Palliative Care Services team at Upstate University Hospital’s downtown campus. They see about 100 patients per month, continuing a steady growth since the service began in 2002, according to Barbara Krenzer, MD, the service’s medical director.
“My goal is to find some hope,” she described. “Let’s change the focus to something we can do something about, like quality of life. This lets the patient take control of things that we can control.” Shaw works in adult palliative care at Upstate University Hospital. She and colleagues provide an array of inpatient services to patients with severe conditions – this includes accident and burn victims as well as patients with cancer and other diseases. Some of them have a chance for recovery, but most are not considered curable. All of them, however, have a prognosis of more than six months. “Palliative care focuses on symptom management and advance directives and can transition to end-of-life care,” Shaw said. The patient’s goals might be pain relief, surviving until a child’s wedding or simply spending one’s remaining
“More people are having the conversation and making decisions sooner,” she said of the growing acceptance of palliative care by physicians and patients. “They see the benefits, the patients themselves and the families ask for it, and physicians and nurses are more comfortable with it.” Money raised from this year’s Upstate Foundation Gala will go toward the palliative care program. Embracing life Social workers are integral to palliative care, assisting with personal and family matters as well as paperwork, explained Chevelle Jones-Moore, a medical social worker at Upstate. She said most patients who select palliative care want to be able to embrace the life they have left. “The services we offer are to try to help the patient live life to the fullest, with a minimum of pain, to provide comfort and to see how we can enhance this person’s comfort,” she said. Among the paperwork tasks for someone in palliative care are deciding: 1. whom to appoint as a health care proxy or spokesperson to carry out the patient’s desires if the patient cannot do so. 2. whether to set up “do not resuscitate” orders; and 3. about advance directives, making it clear what should be done if a feeding tube or breathing machine becomes necessary.
Many families are troubled by such discussions “because ‘end-of-life’ and mortality in the United States is still feared. There’s still a taboo about talking about death and dying,” said Mark Buttiglieri, director of social work at Upstate. Including those who act before and after a diagnosis, he estimates only about 25 percent of cancer patients establish health care proxies. Chevelle Jones-Moore, social worker
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CARING FOR PATIENTS
As for children with incurable diseases, they can receive inpatient and outpatient palliative care through Upstate’s CHOICES program, which also treats children with long-term, medically complicated conditions as well as those with chronic pain. The acronym stands for courage, hope, options, insight, compass (to find one’s direction), empathy and support, explained CHOICES medical director, Irene Cherrick, MD. CHOICES, which adds about six to 10 new patients a month, is usually for patients up to age 19, Cherrick said. “We spend a lot of time creating a trusting relationship with
the family, so then they feel like they can come to us with the needs for their children, being able to advocate for their children, being able to discuss their hopes and their fears for their children, and that takes awhile,” she said. “You have to build a relationship." “I always tell people there’s no ‘d’ in the CHOICES title for death or dying, since most of our patients are not dying but rather living with difficult decisions. Most pediatric patients seen nationwide by a pediatric palliative care specialist are alive a year later. The CHOICES program follows many of these patients for many years.”●
What Hospice offers Patients with a prognosis of fewer than six months are eligible for end-of-life care through Hospice of CNY, an organization that helps families deal with advance directives, pain management and aiming for the best quality of life possible. Hospice care is administered wherever the patient is – at home, at a nursing home, hospital or hospice residence such as Francis House, a 16-bed facility in Syracuse, said Judy Setla, MD, medical director of Hospice of CNY. People should think of hospice “as a set of services, not as a place, because most hospice patients live at home. We also provide medical oversight to nearly all local nursing facilities, and at Francis House, our longtime partner,” she said. “We use a team of highly trained people to address pain, stress and other suffering in the person and their family.” Hospice of CNY works with hospital palliative care teams on a daily basis. When a patient is in his or her last months of life, hospital staff contact Hospice of CNY to visit the patient with information about services available to the patient and family. If Hospice services are accepted, they assist in the transition home, including equipment, medications and other services. Setla wishes more Central New Yorkers used hospice services, which are usually paid for by Medicare, Medicaid and private health insurance plans. Her organization served 1,117 patients in 2014. Onondaga County’s hospice use rate is about 21 percent, she said, below the state average of 29 percent and well below the 50 percent range of the Monroe and Albany county areas. Compared nationally, the CNY region uses Hospice services only half as much, Setla said.
”The reason for low use of hospice in CNY is complex. Physicians and families often have trouble recognizing when a person has shifted from being chronically ill to terminally ill,” Setla said. “Many people, even doctors, don’t know that hospice care is appropriate not just for cancer but for severe lung, heart and neurological diseases like dementia. “There is also a myth that enrolling in a hospice program shortens life. In fact, recent research suggests hospice patients, and those who receive palliative care earlier in various conditions, live longer than those who get traditional care only.”●
Susan Shaw, nurse practitioner PHOTOS BY SUSAN KAHN
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Why you should take
SHARING ADVICE
pain control seriously Pain can be a significant part of the cancer experience for many patients, some of whom are reluctant to take prescription opioids. Some patients fear becoming addicted to medications such as morphine or are concerned about common side effects, such as sedation, itching, constipation and even hormonal imbalances. Brendan McGinn, MD, an assistant professor of anesthesiology specializing in pain management at Upstate, said side effects are easily treated, and cancer patients, especially, can obtain pain relief with appropriate opioid prescribing. “In actuality one of the few indications for chronic usage of these medications is in the treatment of cancer pain,” he said. People with cancer may feel pain from a tumor that physically compresses internal organs, nerves or bones, from surgical trauma or from the effects of chemotherapy or radiation. McGinn said psychological stress can also be a major factor contributing to pain.
McGinn emphasized that pain should be treated aggressively as soon as it become an issue and that staying ahead of pain is essential in helping to reduce its severity. He said studies have shown that having good control of pain can help cancer patients live longer. Standard nonsteroidal anti-inflammatories such as Tylenol and ibuprofen are effective for joint and muscle pain related to cancer, while nerve pain that is more of a burning or tingling sensation may be treated with some antiseizure or antidepressant medication, McGinn said. However, severe pain, no matter what the cause, may require morphine or other types of opioids. In addition to medications, interventions such as nerve blocks and various injections can be utilized to treat cancer pain. Meditation, acupuncture or comprehensive psychological support can also help. “These are all crucial therapies, and they’re often underutilized,” McGinn said. Pain management is one of the Upstate Cancer Center’s support services. Reach the Division of Pain Medicine by calling 315-464-4259 or visiting the support services at upstate.edu/cancer/cancer-care. ●
ways a dietitian can help
Registered dietitians play an important role in cancer care. The Upstate Cancer Center’s Registered Dietitian Nutritionist Maria Erdman gives six examples: l
Patients in treatment for cancer do better when they are well nourished. Erdman said, “a well-nourished patient will have more lean body mass and may be more tolerant of sometimes difficult treatments.” Good nutrition can also help reduce the number of hospital visits and, if someone does have to be hospitalized, the amount of time he or she stays may be reduced.
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Patients who may need the most nutritional intervention include those with head and neck cancers, esophageal cancer and lung cancer. That’s because they may develop difficulty swallowing during treatment and require alternative ways of eating. Some cancer patients experience nausea and vomiting and/or diarrhea. Many cancer treatments target fast-growing cancer cells, and the cells lining the gastrointestinal tract are often affected too, since they are among the body’s fastest-dividing cells.
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Medications can be useful, but how, what and how much a patient eats can also impact symptoms. l
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Some patients who lose weight during treatment also have trouble eating large quantities of food. A dietitian can provide recipes and ideas for foods that are nutritionally dense with good amounts of protein and calories. A patient who must be fed through a tube may require the assistance of a dietitian to help optimize the volume and type of feedings. A dietitian can sometimes help obtain health insurance coverage for these products. People wanting to reduce their cancer risk can also learn from oncology dietitians about the value of good nutrition. One factor in cancer prevention, Erdman said, is to maintain a healthy body weight, remain physically active and eat a wide variety of plant-based foods, including fruits, vegetables, whole grains, nuts, seeds and beans. “Following these guidelines doesn’t mean you won’t get cancer,” she said, “but making healthy lifestyle choices can reduce your risk, no matter what other risk factors you may have.” ●
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SHARING ADVICE
Understanding clues to the seriousness of prostate cancer
Anatomical pathologist Gustavo de la Roza, MD, in his office reviewing prostate cancer slides. He is one of the “Best Doctors in America,” a peer-review honor that recognizes approximately 5 percent of US doctors from whom other doctors would seek care. PHOTO BY SUSAN KAHN
Staging and grading help both patients and doctors understand the severity of prostate cancer.
“Both staging and grading aim to predict the cancer’s behavior, and, on the basis of that, also define treatment,” explained Gustavo de la Roza, MD, director of anatomic pathology at Upstate. Grading can be done early in the process and usually involves examining tissue from a needle biopsy to describe how aggressive the cancer is. The higher the grade, the more aggressive the tumor. Pathologists grade prostate cancer using the Gleason system, which assigns a rating of 1 to 5 to the prostate’s two most cancerous areas, with a 1 meaning the cancer cells resemble normal prostate cells, and a 5 meaning the cells look very abnormal. Those two numbers are added together to get a Gleason score, he explained. The lab report will say, for example, 3+4=7. In general terms, a Gleason score of 6 or less means that the tumor is well differentiated, resembles more normal prostate cells and is less aggressive. A score of 7 would be moderately differentiated, while 8, 9 and 10 are poorly differentiated and very aggressive.
Staging describes how far the cancer has spread. If it is a higher-stage tumor, it could have spread beyond the prostate gland, de la Roza said.
Staging can be pathological, which involves examining tissue from biopsies or surgery, or clinical, which usually involves imaging, such as a CT or MRI scan, as well as a physical exam and lab tests. Staging and grading will help determine treatment, which could range from surgical removal of the prostate to radiation therapy to a “wait-and-see” approach of active surveillance. “In general, the well-differentiated tumors — anything 6 or below — may not need to be treated,” he said. Anything scored above 6 would generally require treatment. De la Roza urged prostate cancer patients to take an active role in treatment decisions. While grading and staging are important in determining treatment, a patient’s age, desires and lifestyle have to be considered, too. “Patients have to be part of the decision-making with the doctors, because it will depend on many, many factors whether they need to be treated or not, and what kind of treatment they get.” ●
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SEARCHING FOR CURES
Will zinc be an element of future cancer treatment?
BY AMBER SMITH
Cancer researchers for decades have focused their microscopes on the tissue where cancer is discovered, be it the lung, the breast, the skin or elsewhere. “Now we are learning it’s not so much where the cancer comes from, but the mutations that cause each individual to develop cancer and allow that cancer to progress,” said Adam Blanden, a fourth-year MD/PhD student in his second year working in the lab of Stewart Loh, PhD, a professor of biochemistry and molecular biology. Research underway in Loh’s lab focuses on mutations of a gene called p53, on chromosome 17, which is implicated in about half of human cancers – regardless of the tissue in which the cancer is found. The gene is a tumor suppressor, meaning it is supposed to stop the formation of tumors. But when the gene mutates, it does the opposite, playing a role in a series of complex molecular events that lead to tumor formation. “There are lots of ways p53 can go wrong, and one way is the loss of zinc,” Blanden said. His work involves restoring proper zinc binding to several zinc-impaired mutations in p53, including the most common mutation that leads to cancers. “This is a fundamentally new way to approach the problem,” he said. “We’re trying to change the environment of the cell so that even if p53 is defective, it can still function. It’s a complete end-around.” The traditional approach, Blanden explained, has been to search for molecular compounds that restore the activity of the mutated p53 by binding to it and “fixing” it. Those attempts have been unsuccessful. Loh and his collaborators at the Rutgers Cancer Institute of New Jersey have discovered a new class of experimental cancer drugs that can reactivate mutant p53 by shuttling zinc ions into cells. Their work appears most recently in the May issue of the journal Molecular Pharmacology; the July issue of the journal Drug Discovery Today and the August issue of the journal Oncotarget.
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Stewart Loh, PhD, and Adam Blanden in the lab where they are developing an experimental cancer drug that, in 10 years, may be used to repair a gene that is implicated in about half of all cancers. At left: two of the journals that have published their research. PHOTO BY WILLIAM MUELLER
A safe, effective treatment is likely at least a decade away, but Blanden imagines it could work like this: A patient receives a cancer diagnosis. Genetic sequencing is done to determine if the patient’s p53 gene is mutated, and if so, if the mutant p53 is one of numerous types that can be reactivated by restoring zinc binding. Treatment would then likely consist of zinc in combination with a drug optimized for that particular p53 mutant. ●
w w w. u p s t a t e . e d u / c a n c e r
SEARCHING FOR CURES
Special Delivery Juntao Luo, PhD, holds a model of a polymer nanoparticle in his Upstate lab.
PHOTO BY WILLIAM MUELLER
Scientist seeks better way to deliver drugs to tumors
The most promising cancer drug can’t be effective if it cannot reach the cancer. Some researchers are trying to solve that problem by developing drug delivery vehicles that transport drugs into tumor cells without damaging healthy cells. Juntao Luo, PhD, an assistant professor of pharmacology whose background is in polymer chemistry and physics, designs and develops nanoparticles that could revolutionize chemotherapy. Carrying proven cancer drugs, nanoparticles are injected into the bloodstream like any injectable medication. They are programmed to travel through blood vessels to solid tumors. Scientists are experimenting with different materials to make nanoparticles, in search of what will work best. Those made of lipids, for instance, were invented decades ago but are too large to diffuse into tumors efficiently and are removed from the bloodstream too rapidly to be effective. The nanoparticles Luo developed are made of polymers, which are substances that contain chains or complicated structures of many molecules. The way in which the molecules are connected determines the polymer’s consistency. Some polymers are rubbery, some sticky, some tough. They are biodegradable, so after they deliver
the cancer drugs, they dissolve and are excreted with urine. Luo believes for cancer drug delivery, polymers will have to be tailored individually to the drug they are carrying, and perhaps also to the patient who will receive the injection. That’s because patients may respond differently to medications, based on the stage and markers of their cancer. His research, while early, shows promise in laboratory animals. Over the summer in the journal Nature Communications, Luo reported about a nanocarrier that can deliver doxorubicin, a potent drug used in a variety of cancers. His laboratory at Upstate identified the optimal building blocks of a specific polymer and designed a drug-binding molecule that would not sacrifice the stability of the nanocarrier. Doxorubicin was then transported in the nanocarrier through the bloodstream to the cancer cells the drug destroys. With a reliable way of transporting the drug through the body to the cancer, Luo explained, doctors may one day be able to safely prescribe higher doses of doxorubicin. “That will increase the efficacy and also decrease toxicity,” he said. It will help the drug be more powerful against cancer, while causing fewer toxic side effects. ●
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LIVING WITH CANCER
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musts for patients
What to consider after diagnosis
A popular guide called “The Cancer Patient’s Workbook – Everything you Need to Stay Organized and Informed” includes a page of advice from Mayo Clinic oncologist Edward T. Creagan, MD. We have condensed what he refers to as the “10 Commandments for the Cancer Patient”: 1. Know your diagnosis. Find out the name, size and grade of your cancer, which will help as you seek information.
6. Acknowledge your limitations. It’s likely that treatment will decrease your energy and focus, so make a list of your priorities and cut back on activities as needed.
2. Know your treatment options. These might include radiation, chemotherapy and/or surgery, both open and minimally invasive.
7. Maintain a list of your medications, dosages and schedule, and the name of any chemotherapy drugs you have taken.
3. Learn all about chemotherapy. What should you expect in terms of survival rates and side effects?
8. Familiarize yourself with palliative care and hospice programs.
4. Recognize the importance of a second opinion. A good doctor should not be offended if you request a second opinion, and chances are he or she can recommend someone.
9. Do not look back with anger or regret. Realize that not every test or treatment will work the way you want it to, PHOTO BY SUSAN KAHN and ruminating over past choices robs you of energy you need in the present.
5. Acknowledge the importance of a support system. Friends, family and even pets can help you physically and emotionally.
10. Be realistic, and spend your time profitably. Traveling around the country collecting multiple medical opinions is probably a waste of time and money; one or maybe two second opinions should be more than adequate. ●
Broccoli, Garlic and Lemon Penne The American Cancer Society’s Great American Eat-Right Cookbook features this pasta dish that highlights a vegetable high in folic acid, vitamins C and K, and fiber. Broccoli is also one of the richest vegetable sources of calcium, iron and magnesium. For quicker prep, buy bagged broccoli florets. For more cheese flavor and fewer calories, grate your own Parmesan cheese into a fine shred so you get more coverage with less cheese. Ingredients
Preparation
½ pound penne pasta
1. Prepare penne according to package directions for al dente (just firm). Two to three minutes before penne is ready, add broccoli. Finish cooking, drain, and set aside.
5 cups broccoli florets or 1 (12-ounce) bag broccoli florets ¼ cup extra-virgin olive oil 10 garlic cloves, thinly sliced ½ cup reduced-sodium chicken broth Grated zest of 1 lemon Salt and freshly ground black pepper ¼ cup freshly grated Parmesan cheese
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Nutritional information, per serving:
2. Meanwhile, in a large skillet over medium-high heat, add oil. Sauté the garlic for 1 to 2 minutes, or until aromatic and beginning to color. 3. Add broth and bring to a boil for 3 to 5 minutes, or until reduced by half, stirring frequently. Add pasta, broccoli, and lemon zest and cook until coated with sauce. Season generously with salt and pepper. Transfer to serving bowl and top with cheese. Serves: 4 Prep time: 15 minutes or less Total time: 30 minutes or less
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395 calories 17 grams fat 5 milligrams cholesterol 135 milligrams sodium
50 grams carbohydrates 5 grams fiber 4 grams sugar 13 grams protein
www.upstate.edu/cancer
MAKING A DIFFERENCE
Future doctors pal around with pediatric patients Between classroom lectures, hospital rotations and their studies, several Upstate medical students make time to connect with young patients at the Waters Center for Children’s Cancer and Blood Disorders. The program called “Peds Pals” matches mostly first- and secondyear medical students and public health students with pediatric patients who have cancer, sickle cell disease or another chronic illness. Interested students are selected through an application and interview process. Students agree to meet with their pals at least once a week in gettogethers that are a mix of academic tutoring and recreation. Many meet more often. Education specialist Kristi Griffin tells the students they may never realize the impact their involvement has on a little pal.
Seventeen first- and second-year medical and public health students were chosen to participate in Peds Pals this year. Above, students Gabriella Izzo and Joe DeMari pose with Connor Licamele at Paige’s Butterfly Run; above right: Connor with Ari Acevedo.
Some students accompany Griffin when she meets with their pal’s teachers, so they can learn about specific academic needs. Some attend medical appointments. Others accompany their pals on fun excursions. And they meet their family members during bi-monthly family events.
“My first year I worked with a child who is now in treatment,” said Heli Shah, now a third-year medical student. “I went to her appointments with her and became a source of comfort. I don’t think I’ll ever forget the image of how much pain the treatments cause.”
WHAT MAKES ‘PEDS PALS’ POSSIBLE? Money raised from Paige’s Butterfly Run helps pay for academic resources, tutoring supplies, iPads, educational games and related materials for the “Peds Pals” program. Paige’s has donated more than $2 million to Upstate since the event began in 1996. The event, which is sponsored by the Upstate Foundation, takes place June 4 next year in downtown Syracuse. Make donations and find details at PBRun.org.
Shah was paired with Brianna Belair this past year. Brianna, 13, is in remission after treatment for a brain tumor that was discovered when she was in kindergarten. Shah often played a board game with Brianna that was designed to help improve memory, and she said she saw improvement in her memory and math skills. Brianna’s mother, Ann Belair, confirmed that her academics improved.
While the students serve as mentors to the pals, the relationships that develop provide a glimpse of what a doctor-patient relationship will be like. Time spent with a pal can be fulfilling, but when a pal suffers a medical setback, students can feel the devastation as well.
Brianna enjoys arts and crafts with Shah and second-year medical student Hannah Carroll. “But I especially like it when they take me out for ice cream,” she said.
Griffin tells the students to remember the magnet on her desk. “You never know when you are making a memory,” it says.
Carroll, whose youngest sister is Brianna’s age, said she likes that the Peds Pals program is so personal. “You meet one-on-one and build a relationship. You get to know them.”
“I truly believe that,” she said. “There may be struggles and heartaches along the way, but what they are doing is life-changing.” ●
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MAKING A DIFFERENCE
O’Hara’s Teal There’s a Cure
The O’Hara family at the walk to raise money for ovarian cancer research.
A match made in marrow
Donor Elizabeth Filkins, right, with the man who received her bone marrow
Ovarian cancer walk/run honors Upstate nurse
She was willing to donate to a stranger. Are you?
The annual run/walk that raises awareness for ovarian cancer changed its name to the Maureen T. O’Hara Teal There’s a Cure 5K this year. It was a way to honor the woman who founded the event in 2008, and who died from the disease in July 2012.
Elizabeth Filkins of Antwerp was inspired to join the National Marrow Donor database because a friend of a friend was battling cancer.
O’Hara was head nurse in the pediatric and adolescent clinic at the Upstate Golisano Children’s Hospital.
She joined Be The Match in 2010, pledging to donate her bone marrow or stem cells to help a stranger. Three years later, she was matched with a 61-year-old man in Kentucky, whom she met more than a year after his transplant. Maureen T. O’Hara
“She was one of those people, if you talked to her for 10 minutes, you realized she had something to teach you about life,” Steven Blatt, MD, director of the General Pediatrics Division at Upstate, told Syracuse Media Group columnist Sean Kirst in an article that appeared before the event. Blatt described O’Hara as “an incredible leader.” Her family continues to organize the run/walk in July in Marcellus, and several Upstate employees continue to participate. This year’s run/walk raised more than $35,000, Kevin O’Hara said, bringing the group’s seven-year total to more than $250,000. Much of the money pays for ovarian cancer research. ●
Bone marrow transplants are used to treat leukemias and lymphomas, inherited immune system or metabolic disorders, bone marrow diseases such as severe aplastic anemia, multiple myeloma and diseases such as sickle cell, in which the red blood cells function poorly. Donors take a series of injections of a drug that boosts the growth of stem cells before they make their donation. Filkins received her final injections and made her donation at Upstate University Hospital in Syracuse, where an apheresis machine separated her blood from her stem cells. The recipient received Filkins’ cells a couple of days later in Kentucky. Filkins told the Watertown Daily Times that Be the Match officials were intermediaries. They let her know the man went home from the hospital and was doing well, and they passed along a hat that Filkins knitted for him while she took the injections. Eventually, the two connected.
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In April, Filkins and her family drove to Kentucky to meet the man who received her cells. She met many of his relatives, too. “Every single one of them were whispering in my ear: ‘Thank you for giving us more time with him.’” Learn about joining the bone marrow registry at bethematch.org. Learn about Upstate’s bone marrow transplant unit on the back cover. ●
www.upstate.edu/cancer
Adding comfort to a hospital stay
MAKING A DIFFERENCE
Alexa Bolton derives so much comfort from the fluffy character towel she brings from home when she is hospitalized, she wants to share that soft touch of childhood with other kids at the Upstate Golisano Children’s Hospital. So Alexa, who is 10 and lives with her parents in Baldwinsville, hosted a charity run in July called “Alexa’s Friends Run.” It raised $11,000, money that will pay for fluffy character towels that Alexa will give to each pediatric cancer patient upon admission. Alexa was diagnosed with an advanced bone cancer called Ewing sarcoma in October 2014. She has required multiple hospitalizations during her treatment, which caused her to lose all of her hair. The run took place at Onondaga Lake Park in Liverpool and asked for a minimum donation of $15. “People were very generous,” said Suzette Bolton, Alexa’s mom. Gifts are still being accepted to the Alexa’s Friends Fund at gchkids.org/alexa
Alexa congratulates runners at her 5K run she started to raise money for blankets for children who are patients at Upstate’s Waters Center for Cancer and Blood Disorders. PHOTO BY WILLIAM MUELLER
ARE YOU GRATEFUL, TOO? When patients are inspired to give back to the hospital where they received quality and compassionate care the Upstate Foundation receives those gifts into any of 800 funds, each representing a program or health concern handled at Upstate. For example, Friends of Upstate Cancer Center is a designated fund to help with needs for cancer patients of all ages and their families. l You
may send a “thank you” to someone on staff at Upstate or a family member through a tribute gift. The recipient will receive notification of the gift (but not the amount) along with your message.
l You
could offer friends and family an alternative to any gift-giving celebration by instead collecting donations for a special occasion tribute gift to Upstate.
l You
can transfer stock shares or other securities as a tax-deductible gift to Upstate.
l You
may have other ideas. Run them by a foundation member by calling 315-464-4416 or emailing FDN@upstate.edu
PHOTO BY KATHLEEN PAICE FROIO
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750 East Adams Street l Syracuse, NY 13210
Bone Marrow Transplant
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Upstate’s Bone Marrow Transplant Program treats patients whose bone marrow has been damaged or destroyed by chemotherapy, radiation or certain cancers or anemias. Marrow, the soft tissue inside bones, is home to most of the immature stem cells that will develop into healthy blood cells; some also circulate in the blood. Cells from the patient or a matching donor are harvested by a needle into a bone or filtered from collected blood and can be frozen for storage. The cells are then infused through a patient’s vein and start growing into healthy new blood cells. Upstate has performed more than 800 such transplants since starting the program in 1992. Patients stay in a specialized unit with specialized nurses to prevent infection and receive multidisciplinary care from a team that might include a radiation oncologist, a dietitian and a social worker. Upstate’s program was recently reaccredited by the Foundation for the Accreditation of Cellular Therapy.