Cancer Care winter 2016

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care

Paige’s turns 20

CANCER

for anyone touched by cancer WINTER 2016

Keeping a song in her heart page 4

Protect yourself from viral cancers page 5

What you need to know about melanoma page 8

Deciphering breast cancer clues in proteins page 9

Brought to you by the

Do you have financial worries? page 13 Sleep well page 16


YOUR GUIDE

Aggressive screening may be factor in high prostate cancer rate The incidence of prostate cancer is statistically higher in Onondaga County, compared to New York state and the United States, but the mortality rate is not significantly different. One possible explanation may be the high level of attention to prostate cancer screening in the community. The Upstate Cancer Center also offers a multidisciplinary prostate cancer treatment program.

per 100,000 people

ONONDAGA COUNTY 225 200 INCIDENCE 175 150 125 100 75 50 25 DEATHS 0

NEW YORK STATE

INCIDENCE

UNITED STATES

INCIDENCE

DEATHS

DEATHS

SOURCE: THE ONONDAGA COUNTY COMMUNITY HEALTH ASSESSMENT AND IMPROVEMENT PLAN 2014-2017

Dedication to care earns national honors Upstate University Hospital received the 2015 Outstanding Achievement Award from the Commission on Cancer of the American College of Surgeons. Upstate was one of a select group of 20 U.S. health care facilities with accredited cancer programs to receive the national honor for surveys performed between Jan. 1 and June 30.

Upstate is one of three institutions nationwide to have received the award for four consecutive surveys (pictured above). The award acknowledges cancer programs that achieve excellence in providing quality care to cancer patients.

“We’re grateful to our entire cancer team, because their dedication to the treatment of our patients and care of their families is what earns us accolades like this one,” says Leslie J. Kohman, MD, medical director of the Upstate Cancer Center.

This magazine received a national award from The Association for Women in Communications. The inaugural issue of Cancer Care from fall 2014 was selected among startup magazines as the “best overall external magazine” and

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received the association’s coveted Clarion Award (pictured above right). Other Clarion Award-winning magazines this year included The Oprah Magazine, Mother Jones, Glamour, Redbook and More magazine. Cancer Care magazine is provided without charge. Call 315-464-4836 to subscribe, or send an email to magazine@upstate.edu with “Cancer Care” in the subject line and a mailing address in the body of the email.

Have you got a story to share? The pages of Upstate’s Cancer Care magazine are meant to be a safe place to share stories of interest to anyone touched by cancer. Some patients and family members are willing to talk about their experiences because doing so may help people facing similar circumstances. Some appreciate the chance to help educate readers about a particular disease or treatment. Others believe that telling their story helps put their lives into perspective. Managing Editor Amber Smith would like to hear from you — by phone: 315-464-4822 or by email: smithamb@upstate.edu ●

upstate.edu/cancer


INSIDE

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Inside this issue CARING FOR PATIENTS

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SHARING EXPERTISE

A rare cancer diagnosis means many tests, decisions

page 4

How cancer produces estrogen in a tumor

page 12

Protect yourself from head and neck cancers

page 5

Raising money concerns with your doctor

page 13

A look at lung cancer

page 6

What are hepatobiliary cancers?

page 7

How processed meats increase your risk of colorectal cancer

page 14

What you need to know about melanoma

page 8

Tips for healthy slumber

page 16

How important is touch?

page 17

Volunteer opportunity

page 18

Keeping memories alive

page 19

Why pharmacists are located in the cancer center

back cover

SEARCHING FOR CURES Proteomics research takes off

page 9

The enzyme that keeps cancer cells alive

page 10

Proteins that spur tumor growth

page 10

Inhibiting cancer cell growth

page 10

One predictor of a poor prognosis

page 11

Proteins that prompt cell death

page 11

LIVING WITH CANCER

MAKING A DIFFERENCE

care

Paige’s turns 20

On the cover: Singer Donna Colton is being treated for cancer of the sweat glands.

CANC

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for an yo ne

tou ch ed

by can cer

WIN TER

Keeping a song her hearin t page 2016

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PHOTO BY ERICA HASENJAGER

care

CAN

WINTER 2016

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

by the

Sleep well page 16

ER

for anyone touched by cancer

WRITERS

Brought to you

Protect from vira yourself l cancers page 5 What you need to kno w abou melanom t a page 8 Deciphe ring breast clues in cancer proteins page 9 Do you have financia l worries? page 13

Jim Howe, Jim McKeever, 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 or events that support the Upstate Cancer Center, 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

Keeping a song in her heart

Donna Colton, right, performing with Sam Patterelli and Sharon Allen at the Respect concert in November 2015.

Treatment for a rare cancer involves many tests, decisions BY AMBER SMITH

What began as a tiny bump under Donna Colton’s scalp has led the 56-year-old woman from Manlius on an ongoing medical odyssey. Colton has undergone surgery and radiation. Now she and her doctors are considering whether she should take tamoxifen, a drug commonly used to treat breast cancer. The words “breast cancer” especially stunned Colton in fall 2014 because she had seen her doctor about a bump on her head, not a lump in her breast. But a laboratory analysis of the growth showed what looked like breast cancer cells. Colton’s doctor hurriedly sent her for a magnetic resonance imaging scan — which showed no signs of cancer in her breasts — and a positron emission tomography scan of her head — which revealed a tiny unusual spot on her left salivary gland. She saw an ear, nose and throat specialist and underwent more testing. Eventually, she got a diagnosis: adenocarcinoma of the sudoriferous glands. She had cancer of the sweat glands. It’s a rare disease, and information is not as easy to find as for more common cancers. One study by researchers at the Mayo Clinic said just 220 cases of cancer of the sweat glands

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PHOTOS BY ERICA HASENJAGER

were reported between 1965 and 1995. This cancer is usually discovered first in the scalp. While it often spreads to other parts of the body, Colton’s cancer was discovered early. Colton has felt stressed, although she has not felt ill. She says, “I felt fine through the whole thing.” Her treatment included an operation by Upstate surgeon Prashant Upadhyaya, MD, who removed the entire bump from her head. That was in the fall of 2014. Then Colton considered the pros and cons of radiation therapy. “The fear was, there could still be microscopic cells floating around,” she says. The treatments could cause permanent hair loss, but more troubling to Colton — a singer — was the potential damage to her vocal cords. Colton met with doctors, including some in Rochester and Philadelphia, and chose Upstate’s Anna Shapiro, MD, as her radiation oncologist. Over the summer, she came to the Upstate Cancer Center five days a week for six weeks for TomoTherapy, an advanced radiation therapy designed to spare healthy tissue that surrounds the cancer. “We used TomoTherapy because of the curvature of the skull,” Shapiro explains. “We were tying to protect the brain, and TomoTherapy is the kind of machine that

Anna Shapiro, MD continued on page 5

upstate.edu/cancer


CARING FOR PATIENTS

Keeping a song in her heart continued from page 4 allows us to treat in an arc pattern.” Shapiro continues to monitor Colton, who was pleased with her treatment. “All the technicians that I saw every day, the people who greeted me at the door, the valet service… it just made this so much easier to deal with,” she recalls. She completed radiation in June. A patch of hair is missing, but her vocal cords were not affected. Her friends organized a benefit concert they called Donnapalooza to raise money for Colton’s unreimbursed medical expenses. Now, Colton is considering the benefits of taking tamoxifen, since her cancer cells contained the estrogen receptors so many breast cancers contain. Doctors have warned her the cancer is likely to be aggressive if it comes back. She wants to be ready, but she does not want cancer to interfere with her music. In November, Colton performed in the “Respect: Central New York Celebrates Women in Music” concert at the Palace Theatre. She chose to sing the Indigo Girls’ “Closer to Fine,” with lyrics that are more poignant since her diagnosis: “There’s more than one answer to these questions pointing me in a crooked line. The less I seek my source for some definitive, the closer I am to fine.” ●

Colton embraces her condition by decorating her bald spot, caused by radiation treatment, with the word “respect.”

Vaccine protects against viral cancers

While smoking-related head and neck cancer rates have declined in recent years, that drop has been offset by a rise in cancers caused by the sexually transmitted human papillomavirus, or HPV. Upstate experts say the HPV vaccine is a simple way to protect yourself. The HPV vaccine was created to protect women from cervical cancer. Now that a strain of HPV has been linked to head and neck cancers, which can affect men and women, “Today everyone coming up from childhood in our society should be vaccinated,” says Robert Kellman, MD, who leads Upstate’s department of otolaryngology and communication sciences. “We believe if we get everyone vaccinated, in another generation we will no longer have the virally caused cancers.”

The same types of HPV that infect the genital areas can infect the mouth and throat, and some research suggests that oral HPV may be passed on during oral sex, according to the Centers for Disease Control and Prevention. Head and neck cancers can affect the voice box, esophagus,

The Centers for Disease Control and Prevention recommend that all women ages 26 years and younger, and all men ages 21 years and younger receive three doses of the HPV vaccine, beginning in childhood.

throat, pharynx, nose and sinuses. Most of those caused by HPV arise at the base of the tongue and tonsils, in an area known as the oropharynx, notes Upstate radiation oncologist Seung Shin Hahn, MD. Typically, such cancers are detected after a patient has soreness, trouble swallowing, a swelling that doesn’t respond to antibiotics, ear pain or persistent hoarseness. Some people might assume they have a tooth problem and see their dentist, who can recognize the symptoms and refer patients to a specialist for testing and treatment. Head and neck cancers that have not spread beyond the neck are most likely curable, says Kellman. Radiation and surgery are the usual treatment options, sometimes with assistance from chemotherapy. He notes that great advances have been made in reconstruction techniques after surgery to remove a tumor. ●

Hear an interview about the HPV vaccine at healthlinkonair.org by searching for “Kellman” or “Hahn.”

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CARING FOR PATIENTS

She never wanted to be a patient; she wanted to remain a person BY AMBER SMITH

What she feared most was pity. Veronica Muscolino didn’t like the idea of telling people about her diagnosis, and then facing pitiful looks. She dreaded the role of lung cancer patient almost more than the disease itself. She and her husband were pleasantly surprised when they came for treatment at the Upstate Cancer Center. “They clearly have selected the right nurses to work there,” says Mickey Muscolino, who is a 26-year employee of Upstate’s clinical pathology department. Nodding in agreement, Veronica Muscolino describes: “They treat us like people, not like patients.” The first sign It was a serious diagnosis, and it came as a shock. What began as an odd twitching in her eye last spring turned out to be a signal of one of the deadliest of lung cancers, small cell lung cancer. As the eye-twitching episodes continued, eventually her doctor referred her to a neurologist, who sent her for a magnetic resonance imaging scan. That revealed lesions on her brain in a couple of areas, which were causing her neurological symptoms. The neurologist referred Muscolino to Dorothy Pan, MD, a medical oncologist at Upstate, who zeroed in on her enlarged lymph nodes. It was the week before Easter when Muscolino underwent a biopsy of her lymph nodes. She and her husband got the results on Good Friday. Stephen Graziano, MD, called them at home. A colleague of Pan’s, Graziano specializes in caring for patients with lung cancer. He’s been at Upstate since he graduated from the University of Minnesota Medical School in 1979, first completing an internship and then residency and fellowship training. Muscolino, a former smoker, began 10 days of radiation therapy in the week after Easter. Then she had six rounds of chemotherapy, with infusions of medication for three consecutive days, and then two weeks off. That course was completed in August. Throughout treatment, she says she has not felt ill, although she lost her hair. She also lost 30 pounds because the taste of food lost its appeal. At her follow-up appointment in late October, tests showed that Muscolino’s tumors were stable or shrinking. More recent tests have shown they are growing.

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Veronica Muscolino during a chemotherapy treatment for lung cancer. PHOTO BY ROBERT MESCAVAGE

Family ties The Muscolinos are in their 40s and live in East Syracuse. Their three children are grown. Veronica works at the Syracuse University bookstore and has been involved in cheerleading coaching for more than 20 years. Mickey, in addition to his job in clinical pathology, has served on the East Syracuse school board and coached basketball. Since the diagnosis, however, the couple has pulled out of those activities. They instead want to volunteer somewhere together. “It is our faith in God that provides us peace and great strength,” Mickey Muscolino says. Graziano says the majority of patients with small cell lung cancer respond well to chemotherapy. If the first round is not effective, patients typically receive a second round. In Muscolino’s case, Graziano has prescribed a different medication, “something the tumor hasn’t seen before.” Muscolino remains positive. She’s learned to accept the generosity of friends who provide meals for her family, accompany her to infusions or help in other ways. She knows they’re not acting out of pity, but of love. ●

upstate.edu/cancer


CARING FOR PATIENTS

Surgeons treat cancers plus other diseases of liver, gallbladder, pancreas

Surgeons Dilip Kittur, MD, and Ajay Jain, MD. PHOTO BY SUSAN KAHN

A LOOK AT HEPATOBILIARY CANCERS Cancers that arise in the liver, gallbladder or pancreas often are not found until they have advanced and caused symptoms. Treatment options may include surgery, tumor ablation, radiation therapy, chemotherapy and/or palliative therapy and pain control.

Surgeons with a hepatobiliary specialization treat some of the deadliest cancers. “Hepato” relates to the liver, and “biliary” refers to the gallbladder and bile ducts. But cancers are not the only problems that require such a surgeon’s expertise.

LIVER Hepatocellular carcinoma is the most common form of liver cancer in adults. It may begin as a small tumor that grows. Or, as is often the case in people with cirrhosis or chronic liver damage, it may present as a series of small cancer nodules located throughout the liver.

Dilip Kittur, MD, and Ajay Jain, MD, care for patients with gallstones, pancreatitis, a variety of cysts, and a condition known as fatty liver, which is related to obesity and can lead to liver cancer. They often use minimally invasive techniques with tiny incisions that reduce a patient’s pain and risk of infection.

Up to 20 percent of liver cancers begin in the cells that line the small bile ducts and are called intrahepatic cholangiocarcinoma. Cancers that begin in the cells lining the blood vessels of the liver are called angiosarcomas or hemangiosarcomas; they are rare and fast-growing.

One of the ways they treat pancreatic cancer is through a complex surgery called a pancreaticoduodenectomy, commonly called the Whipple procedure. This is a procedure in which the widest part of the pancreas is removed, along with part of the small intestine and gallbladder, and sometimes part of the stomach. Jain explains that the Whipple is “a procedure that should only be done at a center that does a lot of them, such as ours. We have a lot of experience, both myself and Dr. Kittur.” The duo is part of the multidisciplinary team of experts that determines a patient’s care at the Upstate Cancer Center. The case of a patient with liver or pancreatic cancer, for example, might be studied and discussed by medical oncologists, radiation oncologists and gastroenterologists, along with the surgeons. “This allows us to approach the problems in a very disciplined and organized fashion,” Jain says. “In this day and age, cancer is treated typically by more than one specialist, so patients may get surgery, and they may get chemotherapy, and they may then get radiation.” ●

COLORECTAL LIVER METASTASES Cancers arising in the colon or rectum spread to the liver in up to 70 percent of those diagnosed with a colorectal cancer. Other cancers less commonly spread to the liver. Also known as secondary liver cancer, these tumors may develop soon after the original tumor develops, or months or years later. GALLBLADDER About nine out of 10 gallbladder cancers are adenocarcinomas, a type of cancer that begins in cells with gland-like properties that line many internal and external surfaces of the body, including the digestive system. Papillary adenocarcinomas are less likely to grow into the liver or nearby lymph nodes and have a better prognosis than most other types of gallbladder adenocarcinomas. PANCREAS Most pancreatic cancers are exocrine tumors, and about 90 percent are adenocarcinomas that begin in the cells lining the pancreatic duct. Islet cell tumors, also called neuroendocrine tumors, represent fewer than 4 percent of pancreatic cancers. SOURCE: AMERICAN CANCER SOCIETY AND MEMORIAL SLOAN KETTERING CANCER CENTER

Hear an interview on this subject at healthlinkonair.org by searching “liver.”

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Carter’s cancer

CARING FOR PATIENTS

Melanomas can appear throughout the body

Former President Jimmy Carter’s skin cancer diagnosis began the way it does for so many others facing the disease. A spot discovered on his liver turned out to be melanoma. Then when doctors ordered an imaging scan, they found four more melanomas on his brain. Carter, 91, disclosed his diagnosis in August. Four months later, he announced that his latest brain scan found no evidence of melanoma — but no one is using the word “cure.” Tim Turnham, the executive director of the Melanoma Research Foundation, told the New York Times that melanoma has a “frightening ability” to return years into remission. Most likely in Carter’s case, the melanoma started somewhere in his skin and traveled via his bloodstream or lymph system to his liver and brain, says Ramsay Farah, MD, division chief for dermatology at Upstate Medical University. The majority of cases of melanoma begin in melanocytes in our skin, although these cells that provide our pigment can be located in other parts of the body. “As the fetus is developing, these melanocytes can migrate to other parts of the body,” he explains. “So even though most of them are in the skin, you find them in the eye, in the gastrointestinal tract, in the lining of the brain. Anywhere you have melanocytes, you can get a melanoma.” News reports say the 91-year-old Carter underwent radiation therapy and has been taking a new immune therapy drug called Keytruda. He receives his care at Emory University’s Kinship Cancer Institute in Atlanta. Farah says Keytruda is an antibody that targets a receptor on a cell of the immune system called a T cell. “Normally T cells have some natural breaks on them so that they don’t attack every cell in your body. When the T cells are sleeping, they’re not going to attack the melanoma,” he explains. “This medicine basically awakens the T cell, so it can awaken its brothers and sisters, and they all attack the melanoma.”

M O L E C H EC K

While some melanomas run in families, most are caused by exposure to ultraviolet radiation from sunshine or tanning beds.

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See your health care provider if you have moles with any of these characteristics: A – asymmetry. Use your mind’s eye to cut the mole in half: Are both sides symmetrical? B – border. Healthy moles have borders that are smooth, as opposed to jagged. C – color. Shades of tan or brown are normal. Troublesome colors are red, white or blue. D – diameter. Moles greater than ¼ inch in diameter are suspicious. E – evolution. Sudden growth of a mole, pain or bleeding warrants examination by a health professional. Some melanomas are hidden, existing in the gastrointestinal tract, an eye or a nail bed. Others, called amelanotic melanomas, have no color but may be felt as bumps on the skin. SOURCE: RAMSAY FARAH, MD

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Former President Jimmy Carter works at a Habitat for Humanity building site in November, in Memphis, Tenn. AP PHOTO/MARK HUMPHREY

Who is more likely to develop melanoma? • Someone with light skin. The pigment in our skin is protective. Melanocytes produce melanin, the chemical that absorbs ultraviolet radiation and protects the cells. People with dark pigment have an incidence of melanoma about 1/20th that of people with light pigment. • Someone who was exposed to high levels of ultraviolet radiation, especially in childhood. Farah says “a lot of the sun damage we see in adults, they acquired it before the age of 12. There is a long latency period for melanoma.” • Someone who lives in an ozone-depleted region. Earth’s ozone layer filters some of the ultraviolet radiation coming from the sun. The highest rates of melanoma are from areas, such as Queensland, Australia, with a hole in the ozone. • Someone with lots of moles. Having 50 or more moles increases one’s risk of melanoma, and having suspicious moles also increases the risk. Farah advocates prevention and vigilant screening so that any melanomas are caught early, before they can spread. ● Hear an interview at healthlinkonair.org by searching “melanoma.”

upstate.edu/cancer


SEARCHING FOR CURES

DECIPHERING BREAST CANCER CLUES IN PROTEINS BY AMBER SMITH

In the laboratories at Upstate Medical University, some breast cancer research focuses on proteins, the microscopic molecules that are present in all living organisms. “Proteins in cells are responsible for doing much of the work within cells, including growth control and elimination of cells that are headed down a path to become cancer,” explains David Amberg, PhD, a professor of biochemistry and molecular biology who serves as vice president for research at Upstate. Cancer arises because of the dis-regulation of key regulatory proteins. Their study — called proteomics — is at the forefront of cancer research. Five Upstate projects that received a share of a $250,000 grant this fall from the Carol M. Baldwin Breast Cancer Research Fund, Inc. involve proteins. In the years since the human genome was completed in 2003, researchers have advanced the understanding of genetic influences that impact cancer. The National Cancer Institute has an Office of Cancer Clinical Proteomics Research, which says genetics “only provides us with a glimpse of what may occur as dictated by the genetic code. In reality, we still need to measure what is happening in a patient in real time, which means finding telltale proteins that provide insight into the biological processes of cancer development.” Compared with genomic research, proteomic research has a number of unique challenges. To begin with, a single gene can encode more than one protein. Some genes encode up to 1,000 proteins. So exponentially more proteins exist in human cells for scientists to understand. Genes may have mutations that cause particular genetic conditions, but protein types can vary from one person to another under different environmental conditions, or within the same person at different ages or stages of health.

WHAT ARE PROTEINS? Large, complex molecules that are essential for the structure, function and regulation of the body’s tissues and organs. Proteins are made up of long chains of amino acids – some of which are made by the body, others that come from the foods we eat. They exist in all living organisms. WHAT ARE ENZYMES? Special types of proteins that are catalysts for a variety of specific biochemical reactions. Their actions can be regulated by temperature, pH level, hormones and other factors. Various enzymes exist in all living organisms. WHAT ARE GENES? The physical and functional units of heredity. Thousands of genes made up of DNA coil together to form each chromosome in all living things, and in humans they are contained in the nucleus of cells. Each gene has instructions for making one or more proteins.

Also, proteins continually undergo changes. They may partner with one another to form complexes. They may bind to cell membranes to regulate membrane trafficking. The genome is relatively static. Perhaps most confounding is the wide range of concentrations of proteins within the body. Blood contains more than a billion times greater concentration of the protein albumin, for instance, than it does of the protein interleukin-6. That makes the detection of a low abundance of proteins tricky — and cruelly paradoxical, since scientists believe the most important proteins for cancer may be those found in the lowest concentrations. Scientists are motivated by challenges like these. They quietly chip away, making progress against breast cancer, one protein at a time. On the next page, take a look at five projects underway at Upstate. continued on pages 10 and 11

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SEARCHING FOR CURES

DECIPHERING BREAST CANCER CLUES IN PROTEINS continued from page 9

CLUE: THIS ENZYME KEEPS CANCER CELLS ALIVE

CLUE: TWO PROTEINS PAIR UP TO SPUR TUMOR GROWTH, SPREAD

Scientists have known for 100 years that cancer cells have a metabolism that’s different from that of healthy cells. They do not depend on oxygen for energy. Instead, they rely on a chemical process called fermentation – yes, the same Stephan Wilkens, PhD process used to make beer – which creates an acidic byproduct that can cause the cancer cells to die.

Hormonal therapy is one of the most successful and least toxic treatment approaches for patients with breast cancer. A drug called tamoxifen has been used for more than 40 years to treat breast cancers that are hormoneMehdi Mollapour, PhD receptor positive – but, more than half of patients are resistant to hormone therapy or develop a resistance over time.

Stephan Wilkens, PhD, and his team in biochemistry and molecular biology want to understand that better.

Research in the laboratory of Mehdi Mollapour, PhD, an assistant professor in the departments of urology, biochemistry and molecular biology, unraveled two key proteins called PP5 and CK2 that are involved in tamoxifen resistance in breast cancer. They act as molecular switches, controlling many biological process in the cell.

They know that to prevent cell death, the cancer cells make more of an enzyme called V-ATPase, which helps rid the cells of the excess acid, and stay alive. Some breast cancers stay put and grow. Others spread quickly to other parts of the body. It’s these more aggressive cancers, it turns out, that contain greater concentrations of V-ATPase. Several laboratories, including Wilkens’ at Upstate, are exploring this phenomenon. The Wilkens team is working with yeast cells, which allows scientists to study the mechanism and structure of the enzyme. V-ATPase is composed of 30 proteins, and it behaves differently in the kidney, for instance, than in bone, or in a cancer. “You can’t just give a drug that inactivates the enzyme, because you would kill the cancer, but also the patient,” Wilkens explains. “We have to be more specific here, more subtle.” Ultimately, Wilkens’ team wants to develop an agent like an antibody that would shut down certain aspects of the enzyme.

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Mollapour says it appears that these two proteins are permanently “switched on” in breast cancers that are resistant to tamoxifen. His research goal is to use the proteins as targets for a new therapy that would treat tamoxifen-resistant breast cancers.

CLUE: INACTIVATING THIS PROTEIN INHIBITS CANCER CELL GROWTH

Cancer biologist Golam Mohi, PhD, focuses his research on an enzyme that exists in greater quantities in the cells of one of the deadliest breast cancers, triple-negative breast cancer. Because Golam Mohi, PhD these breast cancer cells have no estrogen/progesterone receptors, some of the most common breast cancer medications are ineffective.

upstate.edu/cancer


SEARCHING FOR CURES

The image is of a protein called WDR5, a component of the Mixed Lineage Leukemia core complex. It is shown in purple/pink bound to an inhibitor in green. The structure was determined in the Cosgrove lab at Upstate.

“That’s why we got interested,” Mohi says. He explained that the enzyme, Pim-1 kinase, is over-expressed in triplenegative breast cancer, “but if you knock it down, the growth of this breast cancer cell is remarkably reduced.” His laboratory is also experimenting with a Pim kinase inhibitor. When the scientists treat the breast cancer cells with the Pim kinase inhibitor, they see a dramatic inhibition of growth of the cancer cells. In addition to slowing the growth of the cancer cells, this Pim kinase inhibitor also seems to alter the migration or metastasis of the cancer cells, Mohi says. The next step will involve testing the efficacy of Pim kinase inhibition in animal models of breast cancer. Mohi says his research will hopefully identify a new way to treat triple-negative breast cancers, plus provide new insights into the biology of breast cancer.

CLUE: HIGH LEVELS OF THIS PROTEIN LEAD TO POOR PROGNOSIS

The myosin 1e protein plays a role in how well cancer cells stick together and their ability to migrate or spread through the body. In the case of invasive breast cancer, high levels of myosin 1e Mira Krendel, PhD correlate with a poor prognosis, according to research performed by the lab of Mira Krendel, PhD, a cell and developmental biologist. The research team has also shown that removing myosin 1e in laboratory animals can halt tumor growth and slow the spread of cancer cells. While that sounds encouraging, Krendel said that trying to block myosin activity in someone who develops invasive breast cancer has to be done carefully because myosin 1E is required for normal kidney function.

Working with Juntao Luo, PhD, a scientist in pharmacology, she would like to find a way to block myosin function in tumor cells while preserving its activity in other organs. Also, her laboratory may be able to develop the use of myosin 1e as a biomarker. It would work like this: People diagnosed with invasive breast Juntao Luo, PhD cancer would have their myosin level tested. Finding high levels of myosin 1e would suggest a poor prognosis – which may help guide treatment decisions.

CLUE: REMOVING THIS PROTEIN CAUSES CELL DEATH

Breast cancer can be divided into four major molecular subtypes, the most common of which stands out because of the especially active nature of a protein called PAD2. Inhibiting this protein stimulates death Michael Cosgrove, PhD of the cancer cells – and scientists are trying to understand the molecular mechanics involved. “We’re looking for ways to inhibit it, and to do that, we’ve got to figure out how it works,” says Michael Cosgrove, PhD, an associate professor of biochemistry and molecular biology. He and his team discovered that PAD2 targets another protein complex that Cosgrove’s lab works with, called MLL1. “We need to understand how they interact at the molecular level.” The goal is to use that information to develop a new targeted breast cancer therapy. ●

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SHARING EXPERTISE

Understanding how cancer produces estrogen within a tumor BY JIM HOWE

Picture a flower blooming in a desert, and you have the key to a mystery that puzzled cancer researchers for years.

A common type of breast cancer needs the female hormone estrogen and somehow finds a way to obtain it in the bodies of postmenopausal women, who have low levels of estrogen. Just as a desert flower might find a novel way to get water, such as from the air, estrogen-dependent breast cancer can survive in the “hostile environment” of a postmenopausal woman, explains Hironobu Sasano, MD, PhD, a renowned Japanese pathologist. He and other researchers have shown that when little or no estrogen is available in the body, the cancer can produce the hormone within the tumor itself.

In postmenopausal women, the enzyme aromatase can convert the male hormone Hironobu Sasano, androgen into estrogen, Sasano says, MD, PhD explaining the promise and limitations of aromatase-inhibitor drugs in blocking this process.

This discovery marked Sasano as a pioneer in cancer research and intracrinology, a part of endocrinology that studies what takes place within cells, says Upstate pharmacology professor Debashis Ghosh, PhD.

Obesity is involved in the development, recurrence and spread of breast cancer, he says, and reaching and maintaining a healthy body weight means a “significantly better prognosis” for a breast cancer patient, although many other factors come into play.

Another way to think of this is to view the cancer as using “homegrown” rather than “imported” estrogen, says Ghosh, who has collaborated on research with Sasano and hosted his recent visit to Upstate to deliver a lecture on breast cancer, estrogen and obesity sponsored by the Carol M. Baldwin Breast Cancer Research Fund of CNY.

Sasano, chair of the pathology department at Tohoku University School of Medicine in Sendai, Japan, and president of the Japanese Hormone and Cancer Society, also says that the concepts he outlined could be applied to endometrial cancers, as well as to diseases such as osteoporosis, atherosclerosis and even dementia. ●

VISIT WWW..UPSTA AT TE.EDU/BARIAT TRIC CS TO REGISTTER FOR A FREE UPCOMING G INFO SESSION.

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CANCER CARE

winter 2015

upstate.edu/cancer


SHARING EXPERTISE

THE MONEY QUESTION

Financial worries can impact care A patient should be able to talk with his or her doctor about anything. Yet, many patients won’t bring up financial worries. The new cancer drugs approved since 2014 cost more than $120,000 per year of treatment. Many patients may have to pay thousands of dollars out of pocket, which could mean depleting savings or retirement funds, cutting back on groceries, contemplating the sale of a home or filing for bankruptcy. Some patients who have health insurance when they are diagnosed may lose their coverage if they stop working during treatment. The stress of paying for cancer care is a serious concern because it can impact quality of life, hamper a patient’s recovery or lead him or her to skip treatment altogether. When cancer patients are queried on their level of general distress, up to 40 percent list financial distress as a contributor, says Andrew Burgdorf, a clinical pharmacist

at Upstate. “Patients have to be able to talk about financial concerns with their doctor or their provider without fear of compromising their care,” Burgdorf says. If their caregiver doesn’t bring it up, patients can broach the topic by simply saying: I’m having trouble paying for my medications. The National Comprehensive Cancer Network has created a method of rating cancer drugs on their affordability, in combination with evaluations of a drug’s effectiveness and toxicity. The network’s guidelines are available for doctors to share with their patients while discussing treatment options. In addition, Burgdorf points out that many pharmaceutical companies offer patient assistance programs, including copay assistance. Also, a variety of charitable organizations have programs to help people pay for treatment, such as needymeds.org. ●

Distress can be measured, treated – and talked about Years ago, people believed a cancer diagnosis meant death. They were so ashamed of the disease that its name was mentioned only in whispers.

Fast-forward 50 years. “Most people today say, ‘Well, I think maybe I’m going to be OK’ when they get a cancer diagnosis,” says Jimmie Holland, MD, founder of the field of psycho-oncology, who spoke at Upstate this fall. She leads the psychiatric oncology department at Memorial Sloan Kettering Cancer Center in New York.

She credits the attitudinal shift to: l

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development of quantitative tools to measure levels of pain, fatigue, anxiety, depression, delirium and healthrelated quality of life factors. With ways to measure outcomes, scientists could conduct clinical trials that focused on psychosocial issues. celebrities including Betty Ford and Happy Rockefeller coming forward to share their cancer diagnoses. the National Comprehensive Cancer Network, which in the late 1990s embarked on ways to improve psychosocial care for people with cancer. The group’s research led to the use of the less-stigmatizing word “distress” in place of “psychiatric,” “psychosocial” or “emotional.”

Holland says appreciation for the role distress plays in a patient’s healing is slowly catching on. The network’s standard of care guidelines say distress should be recognized, monitored, documented in patient records and treated appropriately. ● Jimmie Holland, MD

winter 2016

CANCER CARE

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SHARING EXPERTISE

How many risks will you take? Processed meats increase your chance of colorectal cancer Meats such as breakfast sausage and marinated turkey breast are ready to cook, and meats such as ham and corned beef are ready to eat. Both types are “processed” meats — and both are carcinogenic. The World Health Organization this fall joined the chorus of health groups warning that bacon, hot dogs and other processed meats can cause cancer. Citing epidemiological studies, the organization said that small increases in the risk of colorectal cancer are associated with eating processed meats. An association with stomach cancer also exists. Data analyzed from 10 studies estimated that eating 50 grams of processed meat daily increases a person’s relative risk of colorectal cancer by about 18 percent. Fifty grams of processed meat is two strips of bacon, or two and a half slices of bologna. Unfortunately, there is no way to make processed meats safer, says Maria Erdman, a registered dietitian nutritionist who specializes in oncology at Upstate. She said not enough research has been done on the new “nitrate-free” processed meats – which are processed with celery seed, a natural source of nitrates – to assess whether they are safer. Centuries ago, before refrigeration, meats were smoked or salted to extend how long they would be edible. Nitrate was used in the form of saltpeter to cure meats and prevent the growth of the bacteria that causes the deadly disease botulism. Meat processors eventually shifted to the closely related sodium nitrite because it was more reliable in its effects, and today, such preservatives are added to meats for flavoring, to improve the appearance or texture of the meat and for food

To reduce your risk: • Replace deli meats with fresh poultry or fish. • Try vegetarian sausage instead of bacon, chorizo or salami. • Replace sausage in chili and soup with kidney beans, chickpeas or lentils. • Sample eggs, cottage cheese or hummus as protein sources. • Save your favorite processed meats for special occasions. SOURCE: AMERICAN INSTITUTE FOR CANCER RESEARCH

safety. The American Meat Institute points out that since sodium nitrite has been commonly used in commercially prepared meats, no cases of botulism have been linked to processed meats in the United States. However, the WHO links about 34,000 cancer deaths per year worldwide to diets high in processed meat. It also says a million people die each year from smoking tobacco. Erdman likes to say that we all have health “bank accounts.” We make deposits when we do things that help our health, such as exercise and eat plant-based foods, and we make withdrawals when we do things that are harmful, such as eat bacon or smoke. She points out that smoking raises a person’s risk of developing cancer much, much more than does eating processed meats. “It comes down, again, to moderation and thinking about what’s important to you,” she says. “We all take risks every day.” How many, and which ones, are you comfortable taking? ●

89.9 & 90.3FM

Now airing on Sundays on WRVO AT 6 AM & 9 PM

Interview examples: pancreas transplant, stroke, prostate cancer, Alzheimer’s disease.

Listen anytime: HEALTHLINKONAIR.ORG or ITUNES (search by topic)

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CANCER CARE

winter 2016

upstate.edu/cancer


BRAIN EXPERTS REGION’S FIRST & ONLY COMPREHENSIVE STROKE CENTER

Upstate welcomes neurologist Hesham Masoud, MBBCh, (left) and neurosurgeon Grahame Gould, MD, (right) 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

CARING FOR PATIENTS. SEARCHING FOR CURES. SAVING LIVES.

winter 2016

CANCER CARE

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LIVING WITH CANCER

Sleep first

7 tips for healthy slumber

Good sleep habits become even more crucial when a person is dealing with cancer. After a diagnosis, people understandably may develop anxiety and/or depression, both of which can impact their ability to get to sleep and stay asleep.

SLEEP HYGIENE TECHNIQUES TAKE ON EVEN MORE IMPORTANCE DURING CANCER TREATMENT. HERE’S A REFRESHER, FROM THE NATIONAL SLEEP FOUNDATION:

“The loss of sleep affects the quality of life. If the quality of their life has already been reduced by cancer, and by anxiety and depression, the goal is not to further reduce it with a loss of sleep,” says Antonio Culebras, MD, a neurologist who specializes in sleep medicine at Upstate.

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Sleep is a brain function, and the majority of chemotherapy medications affect brain function. Many patients taking chemotherapy show signs of memory lapses, trouble concentrating and/or a sleep disorder, Culebras says.

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Be aware that dietary changes can disrupt sleep routines, so now is not the time to experiment with spicy new dishes.

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Exercising vigorously in the morning or late afternoon can promote good sleep at nighttime. A relaxing exercise, such as yoga, in the evening can help initiate a restful night’s sleep.

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Get adequate exposure to natural light, which helps your body maintain a healthy sleep-wake cycle.

He says patients need to bring their sleep issues to the attention of their doctors. A variety of prescription medications may help. “You have to sleep. Once you have slept, then you deal with other problems. But first of all, you have to sleep.” SLEEP-CANCER CONNECTION We already know that sleep apnea raises a person’s risk of stroke, heart disease and dementia. Now research shows a link with cancer. Laboratory studies have demonstrated that low levels of oxygen — the hallmark of sleep apnea — can lead to inflammation, which can fuel cancer cell production. Antonio Culebras, MD, says people with severe sleep apnea may have as much as a 50 percent higher risk of developing cancer.

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Avoid napping during the day, since that can disturb one’s normal patterns of sleep and wakefulness. Close to bedtime, avoid caffeine, nicotine, alcohol and large meals. And remember, chocolate contains caffeine.

Associate your bed with sleep. Establish a regular relaxing bedtime routine and avoid using your bed for watching TV. Create a comfortable sleep environment that is dark and neither too hot nor too cold.

COMFORT FOOD

Cinnamon Apples

Enjoy this recipe as you would homemade applesauce, as a snack or for dessert. Cinnamon apples go well with pancakes, waffles or biscuits. For variety, you may want to add ¼ teaspoon ground nutmeg and ¼ teaspoon ground cloves in addition to the cinnamon. The recipe may help relieve mouth sores, and its fiber content may help with diarrhea. Ingredients

Preparation

3 medium unpeeled tart cooking apples (such as Granny Smith or Braeburn), sliced (3 cups)

1. Place apple slices in 2-quart microwavable casserole or large microwavable bowl. Stir in water, sugar and cinnamon.

½ cup water

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2. Cover and microwave on high 5 minutes.

1/3 cup sugar

3. Uncover and stir. Microwave uncovered about 5 minutes longer or until apples are tender when pierced with fork.

1 teaspoon ground cinnamon

SOURCE: THE BETTY CROCKER LIVING WITH CANCER COOKBOOK.

CANCER CARE

winter 2016

Nutritional information A 2/3 cup serving includes 200 calories 48 grams total carbohydrates 200 milligrams potassium 5 grams dietary fiber

www.upstate.edu/cancer


LIVING WITH CANCER

WHAT YOU THINK YOU KNOW about the importance of touch is probably incorrect

BY JIM HOWE

Kalman says.

As someone who has spent years caring for cancer patients, Upstate nurse practitioner “Katherine “Kitty” Leonard figured that most chemotherapy patients would appreciate a gentle touch during treatment and would fear being touched during invasive procedures, such as inserting IVs.

Nursing studies on touch often divide it into task-oriented or procedural touch versus comforting or caring touch. Leonard says “the big thing that the study showed is there is no big division in the patients’ minds.” She recalls one of the people she interviewed, who, in addition to having cancer as an adult, had been sexually abused as a child. Leonard first expected that the patient’s physical exams would be traumatic, but the patient responded well to uncomfortable and personal procedures when the providers went slowly, listened and explained what they were doing. “That made her feel like she was being listened to and that she was seen as a very whole entity.

Leonard, a former massage therapist, has a longstanding interest in touch. She found that what mattered more than touch to patients was whether they felt they were treated like whole human beings. Leonard’s research into how chemotherapy patients regard being touched was published recently in the journal Oncology Nursing Forum. She designed the research project while studying to become a nurse practitioner with the help of Melanie Kalman, PhD, a professor in Upstate’s College of Nursing. Leonard’s conclusions are based on her interviews with 11 chemotherapy patients, at Upstate and elsewhere. Patients quickly perceive whether health care providers approach them as a whole person or just as a disease, says Kalman. She says not much research has been done in finding out how patients themselves feel about being touched during treatment. Listening to Leonard’s interviews was enlightening. “You hear the same themes over and over. They’re different stories, but the same themes come out,”

“These kinds of stories were really quite pervasive,“ Leonard says. Another patient she interviewed told her that pats on the arm or wrist seem token when the provider was not truly engaged with her as a person. “In years past — before I did this and listened to these people — I would have thought, ‘Oh, just reach out and touch them; touch will make them feel better.’ And it really is not necessarily the case,” Leonard says. Her study taught her that what matters most is that caregivers deeply regard each patient as a unique and whole individual who happens to also have cancer. ●

Hear an interview on this subject at healthlinkonair.org by searching “touch.”

winter 2016

CANCER CARE

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MAKING A DIFFERENCE

Volunteer opportunity: focusing on the patient experience Are you willing to dedicate some time to helping the Upstate Cancer Center? A group that advocates for patients is looking for 10 to 12 additional adult members who are current or former patients, family members, caregivers or Upstate staffers. The Patient and Family Advisory Committee works to improve patients’ experiences in everything from parking and transportation to programs, signage and support groups. The group has about a half dozen current members. In its earlier, larger form, the group gave suggestions about the creation of the Cancer Center, which opened in 2014, says Matthew Capogreco, program and events coordinator for the center. Those interested in joining should be willing to attend monthly or quarterly committee meetings and do subcommittee work, such as research.

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Good sports

Medical student Shunqing Zhang lets cancer patient Connor Stanton, 10, choose from a collection of New Era hats. The youngster (son of Rebecca Quilty of Whitney Point) was pleased to find one for his favorite NFL team, the Seattle Seahawks. PHOTO BY JIM McKEEVER

Medical student arranges hat donations for young cancer patients BY JIM MCKEEVER

It started with a simple, two-word compliment. Upstate second-year medical student Shunqing Zhang was volunteering at the Ronald McDonald House last summer when he saw an adolescent boy wearing a cap with the logo of the Cleveland Cavaliers professional basketball team. “Nice cap!” Zhang told him. Zhang learned that the boy was being treated at the Upstate Cancer Center. The cap had been a gift from the staff, who would regularly purchase caps for sports-minded patients who lose their hair from chemotherapy. The center receives many donations of toys and gifts appropriate for cheering up little kids – but few things that appeal to older kids.

“Compassion, empowerment, knowledge, collaboration and motivation are what is needed for the work,” Capogreco says, echoing the group’s mission statement. “It’s about improving the patient experience and complementing what’s already here.”

Zhang, who is from China, plans to specialize in oncology, partly because his grandfather died from the disease. He got his bachelor’s degree in biology from Cornell University and a master’s degree in interdisciplinary science at Roswell Park before starting medical school at Upstate.

Email Capogreco at capogrem@upstate.edu or call him at 315-464-3605 to volunteer.

He keeps his perspective by spending time with children and their parents at the Ronald McDonald House, which provides lodging to families during children’s medical treatment. While the patients are grateful for the caps, it’s Zhang who is grateful for New Era’s generosity. ●

With guidance from a child life specialist at the center, Zhang reached out to a woman he met while working on his master’s degree at the Roswell Park Cancer Institute in Buffalo. The woman, a Syracuse University graduate, works for New Era Cap Co. As Zhang describes, his request was well received. Now, a box of three or four dozen caps representing a variety of professional and college teams arrives every month. The company sends warm hats, instead of caps, as the weather turns cold. Cancer Center staff enjoy being able to present a patient with head coverings that promote his or her favorite team.

CANCER CARE

winter 2016

upstate.edu/cancer


MAKING A DIFFERENCE

Keeping memories alive PHOTOS COURTESY THE JONES-MOORE FAMILY

Grateful family members donate annually in fathers’ names

PHOTO BY ROBERT MESCAVAGE

BY JIM HOWE

A desire to preserve their fathers’ memories and to help find a cure for the lung cancer that afflicted both men inspired two Upstate employees to make a memorial donation to the Upstate Cancer Center. That’s why the names of Chevelle Jones-Moore and her husband, Brian E. Moore, can be seen among the hundreds listed on two wall displays on the center’s ground floor. “Hopefully our contributions would help, in the best-case scenario, toward finding a cure, but short of that goal, to develop new forms of treatment,” says Moore, a grants and contracts administrator with the Research Foundation for SUNY whose father, Charles E. Moore, was a letter carrier with the U.S. Postal Service in Cleveland, Ohio. Charles Moore shared some things in common with JonesMoore’s father, Isiah “Ike” Jones, a factory worker at Utica

Chevelle Jones-Moore and her husband, Brian Moore, donate to the Upstate Cancer Center in memory of their fathers, veterans Charles E. Moore, above left, and Isiah “Ike” Jones.

Radiator in Utica. Both served in the military (Jones served in the U.S. Navy during World War II and was stationed at Pearl Harbor when it was attacked; Moore served in the U.S. Army and was stationed in Germany during the Korean War). Both men grew up in the South and migrated to the North, and both were smokers who died six months apart; Jones in September 2000 at age 76, and Moore in March 2001 at age 67. Jones-Moore, who meets many cancer patients in her job as a medical social worker, says that in addition to helping keep the memory of their fathers alive, the memorial reminds her and her husband to donate annually toward finding a cure and to spread the message of how “horrendous” smoking is. The Moores perceive smoking as a war, with the war zone being the human body. Chevelle warns future generations, “Do not voluntarily enlist.” The couple reminds us that there are people who have successfully survived this smoking war, thanks to oncology teams such as those at the Upstate Cancer Center. The Moores consider themselves fortunate to have the opportunity to share their memories, but as Brian reflects, “Everyone listed on the memorial wall has a story.” While the two memorial wall displays are now closed to new names, there are many other ways to make memorial donations to the Cancer Center, including an upcoming annual wall display, ceramic plaques in the center’s Healing Garden and various naming opportunities throughout the building. For details, contact the Upstate Foundation at 315-464-4416 or www.FoundationForUpstate.org. ●

winter 2016

CANCER CARE

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750 East Adams Street l Syracuse, NY 13210

UPClose

15.086 0915 39.9M ELsk

Upstate Cancer Center Pharmacy

While nurses help patients settle in for their infusion appointments at the Upstate Cancer Center, the chemotherapy drugs they will receive are prepared in a sterile room just a few steps away by pharmacy technicians and pharmacists who specialize in oncology. Having a dedicated pharmacy team nearby allows for easy collaboration among providers, nurses and pharmacists. In addition, pharmacists are readily available to field patient questions, assist when a patient has an adverse drug reaction and provide answers about oncology medications. Pharmacy technicians Joanne McCollum and Jeremy Gleason at work in the Upstate Cancer Center. PHOTO BY ROBERT MESCAVAGE