Cancer Care

Washington State Medical Association

Hello, Friends!

I have just returned from a weekend attending the annual meeting of the Washington State Medical Association (WSMA). We met as delegates from all the counties in our state at the Murano Hotel in Tacoma, Washington. The theme of the weekend was Celebrating Medicine. We certainly are!

Dr. Dean Martz was named the new President of the WSMA.

Dr. Martz is a neurosurgeon from Spokane, Washington. He hails from Case Western Reserve University and the University of Michigan. Dr. Martz gave a stirring acceptance speech at the Sunday morning House of Delegates. It will be his job to navigate the state medical association through the first full year of the new reality of health care reform. Dr. Martz is definitely up for the challenge.

The WSMA represents over 9600 physicians, physician assistants, residents and medical students in Washington state. Every year we send a delegation to the American Medical Association (AMA) to represent Washington state at this national organization. However, the main purpose of the organization is seen in it's motto...."Physician Driven, Patient Focused". We truly are "focused, focused, focused" on what will be best for patients and their families throughout Washington state.

It was a pleasure and honor being a delegate for the Chelan-Douglas Counties Medical Society.

Best Regards Always,

MItch

Seattle Cancer Care Alliance Network Summit

Hello, Friends!

I have just returned to Wenatchee after meeting with colleagues from the SCCA and fellow Network Site members at the annual SCCA Network Summit. It is a great opportunity to share about how our institutions can help each other reach our mutual goals of high quality patient care for cancer patients in North Central Washington and at all of their network affiliate sites. Dr's Smith and Carlson as well as Mary Gunkel, Larry Sexton, Kelli Van Wagner, and Mall Boyd joined me at the meeting. Key representatives from the SCCA that were hosting the event included Dr. Ben Greer-Network Medical Director, Cecilia Zapata- Director of Regional and Global Network, and Reza Macaraeg-SCCA Network Office.

The keynote address was given by Dr. Frederick Appelbaum of the Fred Hutchinson Cancer Research Center. Dr. Appelbaum is the Executive Director of the SCCA, director of the Clinical Research Divsion at the FRCRC, head of Medical Oncology at UW medicine. It was an honor to hear him speak. Dr. Appelbaum spoke on the coming decade in clinical oncology. 

 Dr. Frederick Appelbaum

Dr. Appelbaum emphasized the need for early detection as a key in minimizing cancer mortality. He emphasized biomarkers, serial sampling and circulating microRNA's as potential strategies for cancer detection.  Dr. Appelbaum next discussed imaging breakthroughs for cancer care. Functional imaging may supplant anatomic only imaging to best care for cancer patients. He then moved to the rapidly developing field of immunotherapy. Immunotherapy continues to show promise in the treatment of several tumor types. He stated that adoptive immunotherapy will become an important therapeutic modality and that application will require centers of excellence. Finally Dr. Appelbaum commented on the societal evolution he and others have observed. There is now rapid and easy access to information. He stated there continues to be new technologies developed but we are approaching the limit to what can be afforded. Therefore it is going to be exceedingly important that we develop partnerships and increase our focus on continuing educating ourselves and our staff.

Once again it is my pleasure to write about Wenatchee Medical Center's relationship with the SCCA.

I wish the best to all our patients, but especially to our patients who have the wonderful and most important role of being a Father. Happy Father's Day!

Best Regards Always,

Mitch

New Prostate Cancer Treatment Approved and Available at WVMC

Hello, Friends! It is an exciting time in oncology as more new and improved therapies for some of our most resistant cancers are being developed and approved.

On April 29th the U.S. Food and Drug Administration approved Provenge for the treatment of metastatic, castrate-resistant prostate cancer. Provenge is a unique therapy recruiting the immune system to fight prostate cancer cells in the body. As there are only a few, modestly effective therapies for castrate-resistant metastatic prostate cancer, this is a welcomed addition. Provenge improves the survival time on average in prostate cancer patients by 19%.

Provenge is a unique therapy and quite different from chemotherapy traditionally given for cancers such as prostate cancer. Provenge is an immunotherapy utilizing the patients immune system to fight the cancer.  Provenge takes white blood cells from the patient's body and then sensitizes them to cancer cells in the lab, then the sensitized white blood cells are re-infused into the patient and those sensitized white blood cells seek out and suppress prostate cancer cells. Immune therapy has a lot of proponents but often the products or concepts advocated for are based on presumption and/or bad science. Provenge is different in that it has met the criteria of efficacy using the strict scientific method and review by experts in the field as well as the Food and Drug Administration.

The process of receiving this therapy is quite unique as well. Three treatments are required about 2 weeks apart. Each treatment is preceded by a procedure called leukapharesis to remove the white blood cells from the body. This procedure is similar to dialysis in which blood is removed from the body. The cells are then removed from the blood by a machine and the blood is returned to the body. The procedure  takes about 3-4 hours. We have contracted with the Puget Sound Blood Center in Seattle to do the procedure for our patients. After the cells are collected they are flown to the company's processing plant in New Jersey to be "sensitized". They are then flown back to Seattle and driven to Wenatchee to be infused approximately 4 days after they are collected in Seattle.

Today we had our Site Inititiation visit from the team from Dendreon Pharmaceutical Corporation. We will be able to begin treatment in the next few weeks. There will be only 50 sites in all the United States that can do this treatment, we will be the only site in Eastern Washington. As a site that actively enrolled patients in the trial leading to the drug's approval, we were selected as one of the first sites in the country to be able to give this treatment to patients. However, due to processing capacity at the lab in New Jersey, at this time we can only treat one patient each month to allow patients from all over the country to have access to this treatment.

I am proud of our research activities that has placed us in such a good position to be the first to bring this exciting new treatment to the patients of North Central Washington.

Best Regards Always,

Mitch G.

New Prostate Cancer Trial

Today we had our site initiation and start-up meeting for our new prostate cancer trial at the Wenatchee Valley Medical Center. Dr. Christopher Haqq and his colleagues from Cougar Biotechnology, Inc. came up from Los Angeles to kick off this new trial at our clinic. The trial is incorporating one of the newest and most exciting therapies for prostate cancer in the preoperative setting. The drug is called Abiraterone Acetate. It blocks testosterone synthesis thus not allowing testosterone to fuel prostate cancer growth. Prostate cancer cells initially are very dependent on testosterone for their survival. Prostate cancer cells go through cell death when testosterone production is blocked by this potent drug.

The design of the trial is for men who have just been diagnosed with prostate cancer and are planning to have their localized prostate cancer treated with surgery. The study will give all the men 24 weeks of treatment before the surgery. Half will receive the study drug Abiraterone for 12 of the 24 weeks, the other half of the men will receive it for the whole 24 weeks. All men will receive an established and effective therapy for prostate cancer called Lupron for the whole 24 weeks. Therefore, no men will be without therapy prior to their surgery.

The study will be limited to the men with the highest risk of their prostate cancer coming back after surgery. The main goal of the study is to demonstrate significant prostate cancer therapy with the medication prior and a significant reduction of the testosterone levels in the prostate gland prior to surgery. This will hopefully lead to a reduction in the number of men in which the cancer returns after the surgery. The surgery can be performed with the standard surgical approach or with the new Robotic Surgery system just now being employed by our urologist at the Wenatchee Valley Medical Center.

We are excited about the collaboration on this new treatment effort between the Urology department and Genitourinary Medical Oncology department from the Seattle Cancer Care Alliance and our organization.

We feel we are in good company. This study is currently offered at only five institutions in the country. Those five institutions are Dana Farber Cancer Center (Boston), Roswell Park Cancer Center (New York), MD Anderson Cancer Center (Houston), the University of Washington (Seattle) and the Wenatchee Valley Medical Center (Wenatchee, WA).

We are so glad to be able to participate in the evaluation of a new therapy that could be a big breakthrough for the treatment of men in North Central Washington with prostate cancer.

Best Regards Always,

Mitch

Mammography Guidelines by Dr. Adrienne Hansen

With the recent controversery surrounding who should have screening mammograms for the early detection of breast cancer, our own Breast Imaging Specialist Dr. Adrienne Hansen wrote the following position paper for the Wenatchee Valley Medical Center:

 NEW MAMMOGRAPHY GUIDELINES

The Wenatchee Valley Medical Center does not accept the new mammography screening guidelines suggested by the United States Preventive Task Force Service. We continue to follow guidelines as put forth by the Society of Breast Imaging, the American Cancer Society and other respected professional organizations.

Provided a woman is not at increased risk for developing breast cancer, we recommend:

Yearly screening mammography starting at age 40 with no upper age limit. 

Yearly clinical breast examination

Optional monthly breast self-examination.

Wenatchee Valley Medical Center

Position Statement on Breast Cancer Screening

 

In November 2009, The Annals of Internal Medicine published the US Preventive Services Task Force’s (USPSTF) updated recommendations for radical changes in the clinical guidelines for breast cancer screening [1].

In summary, these guidelines state that:

 

• Most women in their 40s should not routinely get mammograms

 

• Women aged 50-74 should get mammograms every two years

 

• Data is insufficient for recommending screening mammography once women reach age 75

 

• Women should not be taught Breast self-examination

 

• Evidence is insufficient to support health care providers performing Clinical Breast Exam

 

The Wenatchee Valley Medical Center does not accept these new recommendations. The federally funded and staffed Task Force includes representatives from major health insurers, but does not include a single radiologist, oncologist, breast surgeon, or any other clinician with demonstrated expertise in breast cancer diagnosis or treatment.  We continue to follow guidelines as put forth by the Society of Breast Imaging, the American Cancer Society and other respected professional organizations. 

Provided a woman is not at increased risk for developing breast cancer, we recommend:

Yearly screening mammography starting at age 40 with no upper age limit. 

Yearly clinical breast examination     

Optional monthly breast self-examination.

Over forty years of research has supported an unequivocal reduction in the risk of death for women undergoing screening mammography. In the United States, the mortality rate from breast cancer remained static for 50 years preceding the onset of national screening mammography in the mid 1980s. With the onset of rigorous screening mammography in 1990, the death rate has decreased by 30%, certainly a noteworthy achievement.

 

The USPSTF report underestimates this reduction to be 15% in women ages 39-49, 14% in women ages 50-59 and 32% in women ages 60-69, and uses these figures in their calculations of how many women need to be screened to save one life [2]. These are low estimates of benefit, and this figure ignores recent direct studies from the Netherlands and Sweden. Across all age groups, at 20 years of follow-up, women who participated in screening had a 44% decrease in risk of death from breast cancer (RR .56; 95% CI 0.49-0.64) compared to those who were not screened [3]. In British Columbia, there was a 40% decrease in deaths among women screened annually between ages 40 and 79 between 1998 and 2003, and a 39% reduction among women aged 40-49 at first screen [4].

 

Breast cancer is less common in women aged 40-49, which is why more women in this age group need to be screened to save the same number of lives when compared to older women. However, the number needed to screen produced by the USPSTF is significantly elevated due to the underestimation of the decrease in mortality rate discussed above and the use of a number needed to invite to screen instead of a number actually screened. The USPSTF used a 15% decrease in breast cancer deaths among women in their 40s invited to screen, and estimated that 1904 women in their 40s would need to be invited to screen to prevent one death from breast cancer.  Using the USPSTF’s flawed algorithm and a modest 30% decrease in death, the number needed to screen drops to 952.  As breast cancers in younger women often are faster growing, women in their 40s should be screened annually. The average size of a breast cancer diagnosed today is significantly smaller than cancers diagnosed 20 years ago.

 

While it is true that mammography is less well studied in women over the age of 75, breast cancer is more common in this age group. Women at age 75 vary greatly in their overall health and life expectancy. We believe that it should be an individual decision between a health care provider and a woman as to whether or not screening is appropriate, so that a healthy 75 year old woman may still potentially reap the benefits of screening.

 

High quality mammography, with radiologists who are considered high volume readers, helps to cut back on the additional testing (“harms”) of mammography. Mammography should not be limited to high risk women, since approximately 75% of breast cancers are diagnosed in those with no risk factor other than their age and being female.

 

We do agree that monthly, regimented breast self-examination (BSE) is not appropriate for all women and may bring anxiety to some. For women who are comfortable performing BSE, we do not discourage it. All women should be encouraged to report clinical concerns to their health care provider.

 

Clinical breast examination (CBE; performed by a health care provider) is complementary to mammography since a small percentage of breast cancers are felt but are mammographically occult.  We believe that clinicians should continue to be trained and should continue to perform CBE as part of a routine physical examination.

 

A.    Adrienne Hansen, M.D.

    Breast imager, Department of Radiology

 

1. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;151:716-726. 

2. Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2009;151:727-737.

3. Tabar L, Yen MF, Vitak B, Chen HH, Smith RA, Duffy SW. Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet. 2003;361(9367):1405–1410.

4.  Coldman A, Phillips M, Warren L, Kan L. Breast cancer mortality after screening in British Columbia women. Int J Cancer 2007;120:1076–1080.

5. Berg WA, Hendrick RE, Kopans DB, Smith RA. Frequently asked questions about mammography and the USPSTF recommendations: a guide for practitioners. www.sbi-online.org.

Washington State Medical Association Legislative Summit

Hello, Friends! It has been a long time since my last blog.....I will not let that happen again.

Yesterday we had the privilege of being in Olympia with a group of physicians to discuss the best strategies to improve health care for patients in North Central Washington. Many budget issues were on the table and many legislative initiatives address how some Washingtonians receive health care. The looming issue that all lawmakers in Olympia and the Governor are dealing with is the $2.6 billion budget deficit that exists for this year.

The morning meeting included a speech by Governor Gregoire. The Governor skillfully articulated the challenge of balancing a budget. Over 70% of the expenditures in the budget are not available for reduction due to the Washington Constitution and/or because of state law. Unfortunately health care expenditures are not under the protection of the constitution or state law. Therefore, many "cuts" in health care are proposed to remedy the deficit. The Governor's budget will eliminate the Basic Health Plan which insures 65,000 Washingtonians and has 86,000 on the waiting list. Eligibility for the "Apple Health for Kids" will be reduced from 300% of the Federal Poverty Level to 205%. Dental and hospice services would be suspended. The Governor was quick to state that the "all cuts budget" submitted was "unacceptable" and "unjust" and that she would fix the cuts as soon as possible.

The afternoon was spent meeting with Senator Linda Evans Parlette, Representative Mike Armstrong, and Representative Cary Condotta. They were all gracious, humorous, and clearly knowledgeable on the pertinent budget issues up for discussion.

The WSMA takes the following positions:

• Gravely concerned about the recommended cuts to the Basic Health Plan and the General Assistance Unemployable Medical funding.
• Opposes the suspension of interpreter services paid by Medicaid
• Medicaid and BHP and other vital health services should be appropriately funded and not subject to any cuts so that patients can have access to care when they need it

WVMC is committed to continue to fight for the health and welfare of our patients and their families.

Sincerely,

Mitch G.

Non-Hodgkin's Lymphoma and Anticoagulation

Hello again from New Orleans and the 51st annual meeting of the American Society of Hematology! The weather has been rainy and cold outside, but in the presentation halls of the convention center the data being shared is Hot (and sometimes hotly debated!)

I attended the Oral Scientific Session for Non-Hodgkin' Lymphoma (NHL). Two of the presentations are worth discussing and may change therapy for our patients diagnosed with different subtypes of NHL.

The first discussion was in regards to a study comparing Bendamustine in combination with Rituxan to the standard chemotherapy of CHOP + Rituxan in patients with Follicular NHL. The results strongly favored Bendamustine. The combination of Bendamustine and Rituxan led to improvement in the time until lymphoma returned by approximately 20 months! In addition there was less side effects than to the standard chemotherapy including less infections and no hair loss! Because this is only one study from Germany, many investigator and physician scientists feel that this study needs to be repeated more broadly to verify the benefit. WVMC will hopefully be participating in this important study. I met with a representative from Cephalon pharmaceutical company to begin the process of making WVMC one of the North American sites for this large international study.

The next discussion was on a very aggressive subtype of NHL called Mantle Cell NHL. The study compared three chemotherapy regimens....two aggressive regimens (one of which includes a stem cell transplant) and one standard regimen (CHOP+Rituxan). The two aggressive regimens were equivalent and both better than CHOP+R in leading to longer life expectancies for patients with this lymphoma.

Finally, the lead presentation at the Plenary Scientific Session was on the use of a new oral medication for anticoagulation (or blood thinning) in patients with a blood clot in their leg or lungs. The standard medication used for 50 years has been warfarin. Warfarin is difficult for patients to use because you have to adjust your diet and have laboratory monitoring every 2 weeks (if not more). The new medication is called dabigatran. It does not require monitoring and can be taken with or without food. The study showed it had the same effect in reducing recurrent blood clots, and with less of the side effect of bleeding. This may be a major breakthrough for our patients that require anticoagulation for various reasons.

That is all for now. I look forward to heading back to Wenatchee tomorrow and getting back in the clinic with all my wonderful patients.

Best Regards,
Mitch

American Society of Hematology Annual Meeting - New Orleans, LA

Hello from New Orleans!

New Orleans is the site of this year's annual meeting of the American Society of Hematology, the world's largest professional society composed of over 15,000 members and is dedicated to the understanding of hematologic conditions and diseases and to development of treatment of these disorders.

The society's goal is best state by it'smission statement "The American Society of Hematology (ASH) is the world’s largest professional society concerned with the causes and treatments of blood disorders. The mission of the Society is to further the understanding, diagnosis, treatment, and prevention of disorders affecting the blood, bone marrow, and the immunologic, hemostatic and vascular systems, by promoting research, clinical care, education, training, and advocacy in hematology." I am very pleased to be a member of this organization. If interested, more information can be found on their website hematology.org.

Today I attended many interesting meetings and heard discussion on a variety of topics that are directly applicable to patients with hematologic conditions in North Central Washington. Although the "meaty" scientific presentation are yet to come, here is a taste of the discussions from today:

Chronic Lymphocytic Leukemia

Many molecular characteristics for patient with this form of leukemia are being defined to help us better know who needs treatment with chemotherapy. Since some patients may have this disease for years without everdeveloping any symptoms or complications, it is important we pick out the patients for chemotherapy that really need it. Disease characteristics that would suggest the patient needs to be treated now instead of later include ZAP 70+, non-mutated IgG Variable heavy chain, Del of 11q or 17p on chromosome analysis. Although it may be difficult to understand some of these terms, be assured that we will take all these important characteristics into consideration when we develop a treatment plan for your leukemia.

Olfamtumab was just approved by the FDA for treatment of patients with CLL resistant to other forms of chemotherapy and immunotherapy. It is an antibody targeted to CLL cells for very directed leukemia cell kill. We now have the opportunity to use this agent in Wenatchee and our satellite clinics in Omak and Moses Lake.

Follicular Non-Hodgkin's Lymphoma (NHL)

One of the most practice changing presentations that may come from this meeting will be presented at the scientific oral session on Monday afternoon in regards to the treatment of follicular NHL. Preliminary discussion is that the new drug Bendamustine will supplant the traditional chemotherapy of CHOP when given with Rituxan as the best new First-line therapy for patients with follicular NHL

Other information discussed was that prolonged follow-up in patients who have received rituximab for 2 years after their treatment for follicular NHL continue to show that it keeps the lymphoma from coming back for longer.

Diffuse Large B-Cell NHL

For this group of patients with aggressive NHL a few old issues were discussed with more clarification. There is no benefit continuing rituximab for 2 years as is seen in patients with follicular NHL as discussed above. Radiation therapy to large areas of lymphoma after chemotherapy does not add to patient's benefit after chemotherapy. There is a better defined sub-group called Germinal Center Subtype that does better with chemotherapy than other sub-types.

I hope this information is helpful to those back home who are dealing with these conditions. I know we are continuing to make more and more progress in understanding, and thereby, treating these conditions.

Three more days of meetings, more to come!

Best Regards,

Mitch

Seattle Cancer Care Alliance and WVMC's Annual Retreat

Collaboration is great!

Today we held our annual retreat between us and the Seattle Cancer Care Alliance (SCCA). In 2007 the Wenatchee Valley Medical Center (WVMC) partnered with the SCCA as a Network affiliate site. By doing so, our hope was that our cancer patients would have the best cancer care offered anywhere in the country. Our hopes our coming to fruition.

The SCCA is made up of the University of Washington, Fred Hutchinson Cancer Research Center and Seattle Children's Hospital. The SCCA is a designated Comprehensive Cancer Center by the National Cancer Institute (NCI). As described on the NCI website, "NCI-designated cancer centers are characterized by scientific excellence and the capability to integrate a diversity of research approaches to focus on the problem of cancer. They play a vital role in advancing towards our goal of reducing morbidity and mortality from cancer." It is because of the excellent scientific work recognized by both us and the NCI and because of the compassionate care provided to our patients, we decided to partner with the SCCA. The partnership has become most satisfying.

Today Dr. Benjamin Greer, Network Medical Director and Dr. Marc Stewart, SCCA Medical Director brought their team over the passes to meet with us to see how we could improve cancer patient care between our two organizations. Accompanying Dr. Greer and Dr. Stewart was Geoff Austin, Oncology Service Line Administrator, Cecilia Zapata, Director of Planning and Strategic development, Tove Thompson, Network Clinical Research Manager, Lisa Lim, Network Coordinator, Jim Barker, Network Marketing, and Autumn Mumaw, Oncology Concierge. Both Dr. David Weber, WVMC Chairman of Board and Dr. Stu Freed, Medical Director of WVMC were at the meeting indicating WVMC's deep commitment to cancer care for patient's of north central Washington.

Our agenda was extensive. We discussed research collaboration for our patients. Research is the cornerstone of advancing cancer care so that treatment in the present and the future will be advanced as quickly as possible. Appropriately it had a prominent place in our discussion today. We heard of the focused, directed efforts the SCCA if giving to survivorship issues which is clearly recognized as such an important issue for those who have completed their cancer treatment. We shared on our new survivorship's efforts (see my first blog) and updated them on our third survivorship retreat held last weekend, free of charge to all survivors that came, at Sun Mountain Lodge in Winthrop. We discussed communication issues between the two organization to continue to strive to make the patient's experience seamless for those whose best and most appropriate cancer care requires treatment at both institutions.

I am deeply grateful to Dr. Greer and the SCCA for their personal attention to our patients here in north central Washington. We look forward to many more years of meaningful collaboration.

Best Regards Always,

Mitch G.

Lung Cancer - New Clinical Trial

This week we had our site initiation meeting for a new clinical trial in patients with stage IV non-small cell lung cancer. We are excited about the possibility of this promising treatment for our lung cancer patients in North Central Washington!

Lung Cancer is one of the most difficult cancers to treat. Lung cancer is most curable when it is in its earliest stages. We have the chance to cure lung cancer all the way up to Stage III disease (there are four stages, I-IV). The higher the stage, the more difficult it is to get rid of the cancer completely. Lung cancer causes the most cancer deaths in both men and women in the USA and is the second most common cancer in both men and women (prostate and breast cancer are more common in men and women respectively). Stage IV disease represents lung cancer that has spread from the lung to other parts of the body. These tumors that originated in the lung but have spread to other places and are growing there are called metastasis. The standard treatment for stage IV lung cancer is chemotherapy. Although chemotherapy has been demonstrated to increase both survival time and quality of life in patients with stage IV lung cancer, there is so much room for improvement.

This new clinical trial is for patients with stage IV non-small cell lung cancer. Various hospitals, clinics and oncology offices are opening this trial right at this time all across the USA. The trial is designed to compare the standard chemotherapy for stage IV disease with a promising new combination of chemotherapy drugs. We are one of the first clinics to have this trial now available to our patients.

The way the trial works is that patients with newly diagnosed stage IV lung cancer are considered eligible for the trial. After reviewing information on the trial and signing a consent form to participate in the trial, each patient will be selected to one of two groups . The first group will get the standard chemotherapy consisting of the drugs carboplatin, paclitaxel and bevacizumab. The second group will get selected for the new, promising combination of drugs consisting of carboplatin and premetrexed. Both groups will be followed over time. After several years of observation and care, and after several hundred of patients have participated across the country, we will then know which group lived longer and had the best quality of life. We are hoping this will be a great advance for our stage IV lung cancer patients!

We are committed to bringing novel and exciting treatments to patients with all cancers. We thank and respect all patients who are willing to participate in such important and promising oncology research.

Best regards always,

Mitch G.