IN THIS ISSUE

5 INITIATIVES: NCI grant will transform community cancer care

7 URGENT CARE: Onsite unit helps patients avoid the Emergency Room

8 IN THE LAB: New technology spurs the hunt for cancer

The Helen F. Graham Cancer Center & Research Institute recognized as national model for treatment of head and neck cancersWhen Wilmington Realtor Brian Ferreira was diagnosed with oral cancer, he could have gone just about anywhere for treatment. He chose the Head and Neck Cancer Multidisciplinary Center (MDC) at the Helen F. Graham Cancer Center & Research Institute.

“I went to Philadelphia for a second opinion, but I came back to the Graham Cancer Center for my care, and I was not disappointed,” he said. “I never felt like just another patient. My doctors and the entire MDC team took a personal interest in my very personal illness.”

At the Head and Neck MDC, a surgeon, medical oncologist and radiation oncologist team with health professionals from every pertinent discipline – a nurse navigator and research

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I s s u e N o . 3 0

Robert Witt, M.D., and Neil Hockstein, M.D., of the Head and Neck Cancer Multidisciplinary Center

CONTINUED

2 HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

nurse, a dental expert, a speech pathologist, a dietitian, a health psychologist and a social worker. The entire team has one focus: an effective treatment plan for each patient’s particular type of cancer.

This unique model of multidisciplinary cancer care, introduced 10 years ago at the Helen F. Graham Cancer Center & Research Institute, is the standard for leading institutions around the country and abroad. Studies show that patients do better in this type of multidisciplinary care setting.

“Given the multiple primary treatment modalities used to treat head and neck cancers, participation by a comprehensive multidisciplinary core of physicians and specialists is essential,” said MDC Director Robert Witt, M.D. In addition to his clinical work, Dr. Witt is an internationally recognized researcher and book editor in salivary gland diseases and thyroid cancer.

Recently he received, as principal investigator, a four-year, $2.5 million R01 National Institute of Health grant to continue groundbreaking efforts to generate artificial salivary glands in the laboratory. Dr. Witt hopes this research will soon improve the quality of life for patients whose own salivary glands are damaged by radiation therapy.

Next generation medicines target more prolific cancers

Incidence of head and neck cancer is skyrocketing, particularly for mouth cancers induced by the human papilloma virus or HPV. The good news, according to Medical Oncologist Charles Schneider, M.D., is, “These viral-induced cancers have a significantly better prognosis compared to cigarette and alcohol-induced head and neck cancer, and also respond extremely well to chemotherapy and radiation.”

Most patients with regionally advanced head and neck cancers (both HPV-positive and negative) experience high cure rates when treated with a combination of chemotherapy and radiation. “We have transformed a disease with an historically dismal prognosis into one that is highly treatable and usually curable,” said Dr. Schneider.

New biologic agents offer more targeted therapy with fewer side effects than traditional chemotherapy drugs. Sophisticated radiation technologies such as image-guided intensity modulated radiation therapy and volumetric modulated arc therapy (soon to be instituted) dramatically reduce treatment times and optimize radiation doses to precisely target cancer cells.

H E A D A N D N E C K M C D | Advanced & Individualized Care

COORDINATING A PLAN

The Head and Neck MCD team meets to

discuss a patient’s plan of care ensuring

what is the best course for the patient.

GRAHAM CANCER CENTER RECOGNIZED AS NATIONAL CARE MODEL | CONTINUED

CONTINUED

November 2014 CANCER UPDATE 3

Less invasive surgical techniques shorten hospital stays and improve recovery. For some types of hard-to-reach cancers, for example, those located in the oral and nasal cavities, minimally invasive da Vinci® robotic surgery may be the best option. Otolaryngologist and Surgeon Neil Hockstein, M.D., pioneered this technology nearly a decade ago while at the University of Pennsylvania School of Medicine and has published extensively on its capabilities.

“One tremendous advantage of the Head and Neck MDC,” he explained, “is that the patient’s physicians and other health professionals meet face-to-face. Together we can coordinate their plan of care and actually talk to one another about what is best for the patient.”

This process not only promotes best practices, but shortens time to treatment and enables patients and their family members to meet with their entire cancer care team in a single visit.

“When Dr. Hockstein, my surgeon, explained all the reasons why surgery was not the best way to treat my cancer, and that the MDC offered better options, it really impressed me,” Ferreira said. “It raised my comfort level to know I was getting an honest picture of my condition and that the Graham Cancer Center is where I would get the best care.”

At the MDC, each patient has a personal guide through the cancer treatment process — a certified oncology nurse navigator, who collaborates with the rest of the team to help navigate, answer questions and respond to concerns. A certified research nurse enrolls patients in clinical trials and follows them throughout their trial experiences.

Depending on the patient’s individual needs, experts in other fields may join the team. In addition, the Graham Cancer Center offers a host of specialized services, including survivorship, pain and symptom management, genetic counseling, wellness and well-being programs, pastoral care,

smoking cessation and a follow-up clinic for young adults who have survived childhood cancer.

For Ferreira, the journey was never solitary. “Throughout my treatment, I genuinely felt that all the people I worked with at the Graham Cancer Center really cared about my prognosis and would help me get to where they expected me to be,” he said.

Leveraging the latest research findings

As one of only 34 community sites in the nation selected by the National Cancer Institute as a Community Oncology Research Program (NCORP), the Graham Cancer Center offers access to state-of-the-art clinical studies for patients with both early and advanced head and neck cancers.

Studies underway at Christiana Care through the NCI clinical trials program include testing a targeted immunologic agent called cetuximab that interacts with radiation as a sensitizer and enlists the immune system to disrupt cancer growth and metastases; afatinib to treat recurring cancers and bevacizum-ab for metastatic disease. Radiation Oncologist Adam Raben, M.D., recently introduced a Phase I trial in collaboration with University of Colorado Health Science Center incorporating a targeted agent (PI3K) with chemotherapy for HPV cancers.

Evidence suggests that patients do better when enrolled in a clinical trial and when treated at centers with high clinical trial accruals. Currently 24 percent of patients at the Helen F. Graham Cancer Center participate in clinical trials — well above the national average. ¤

CHARLES SCHNEIDER, M.D.

“

„

We have transformed a disease with an historically dismal prognosis into one that is highly treatable and

usually curable.

One tremendous advantage of the Head

and Neck MDC, is that the patient’s physicians and

other health professionals meet face to face.

“

„NEIL HOCKSTEIN, M.D.

4 HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

Researchers on the fast track to developing artificial salivary glands could speed relief from some radiation therapy side effects

Graham Cancer Center hosts first Tissue Engineering Summit

The largest group in the nation collaborating to create artificial salivary glands in the laboratory gathered at the Helen F. Graham Cancer Center & Research Institute in August 2014 to discuss their progress. Principal Investigator Robert Witt, M.D., director of the Multidisciplinary Head and Neck Cancer Center, and Swati Pradhan Bhatt, Ph.D., director of Tissue Engineering at the Center for Translational Cancer Research, hosted the two-day summit attended by team members from the University of Delaware’s Materials Engineering and Biological Sciences Departments, Rice University in Houston and Allegheny Health System in Pittsburgh. Also attending were scientists from the National Institutes of Health, which awarded the team $2.5 million to fund the project over the next four years. The research team has grown to include some 25 investigators, under the leadership of Dr. Witt and co-principal investigators Cindy Farach-Carson, Ph.D., a biologist at Rice University and Xinqiao Jia, Ph.D., a materials engineer from the University of Delaware. ¤

F E A T U R E D E M P L O Y E E

Paula Furtado

Office Supervisor for Genetics, Oncology Nutrition and Psychosocial & Survivorship, at the Helen F. Graham Cancer Center & Research Institute

As an office supervisor for several different cancer care programs, I know that promoting teamwork and good communication is key to delivering optimum patient care. It is imperative that as a team, we give our patients the help they need in a timely manner, but also in a way that is comforting and reassuring. I am extremely proud to be a member of this team that works hard to give our best to our patients and their families. ¤

November 2014 CANCER UPDATE 5

The National Cancer Institute has selected Christiana Care’s Helen F. Graham Center & Research Institute to join its Community Oncology Research Program (NCORP), an elite network of cancer centers in communities throughout the United States.

A five-year, $8.2 million grant from NCORP bolsters Graham Cancer Center initiatives to bring leading-edge cancer screenings, prevention, control, treatment and imaging research trials to more people in places closest to where they live and work.

The Graham Cancer Center is one of only 34 NCORP Community Sites joined by 12 Minority/Underserved Community Sites that will implement the latest, most scientifically advanced clinical research designed and led by NCORP. These clinical trials will bring added opportunity to test new technologies and strategies to fight cancer. They will also enable research on how cancer care is delivered in today’s changing health care environment, all with an eye toward improving outcomes and reducing disparities of care.

“Making quality cancer care more accessible to our patients is the hallmark of Christiana Care’s cancer program and mission,” said Nicholas J. Petrelli, M.D., Bank of America

C A N C E R C E N T E R I N I T I A T I V E S | Improving Outcomes

National Cancer Institute Research grant will transform community cancer care

AN ELITE GROUP

The Graham Cancer Center is one of only 34 NCORP

Community Sites that will implement the

latest, most scientifically advanced clinical

research.

Medical Oncologist Stephen S. Grubbs, M.D., is the NCORP principal investigator at the Helen F. Graham Cancer Center & Research Institute

Graham Cancer Center hosts first Tissue Engineering Summit

CONTINUED

6 HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

The five-year, $8.2 million

grant from NCORP bolsters

Graham Cancer Center

initiatives bringing leading-

edge cancer screenings,

prevention, control,

treatment and imaging

research trials to more

people in places closest to

where they live and work.

NCI RESEARCH GRANT | CONTINUED

In partnership with NCORP, we can change

the landscape of cancer care delivery

in Delaware and throughout the country in similar communities,

where we know 80 percent of patients

receive their cancer care.

“

„

endowed medical director of Christiana Care’s Helen F. Graham Cancer Center & Research Institute. “In partnership with NCORP, we can change the landscape of cancer care delivery in Delaware and throughout the country in similar communities, where we know 80 percent of patients receive their cancer care.”

The Graham Cancer Center is one of the original NCI-selected Community Cancer Center sites (NCCCP) and has been a leader in NCI’s Community Clinical Oncology Program (CCOP).

NCORP builds on and replaces these two previous NCI community-based clinical research programs (NCCCP, CCOP) that have helped drive down cancer rates. In 2002, Delaware had the highest cancer mortality in the nation. Today, the First State is number 14 on that list, and cancer mortality rates for both men and women are dropping nearly twice as fast as the national average.

Christiana Care Medical Oncologist Stephen S. Grubbs, M.D., is the NCORP principal investigator at the Graham Cancer Center. “These programs show that when local physician investigators collaborate on national community-based studies, our patients benefit greatly because they gain access to the most promising cancer fighting strategies without having to leave the comfort of familiar surroundings,” said Dr. Grubbs. “Membership in NCORP is a natural progression for our program,” he said. ¤

NICHOLAS J . PETRELLI, M.D.

Bank of America endowed Medical Director

The Helen F. Graham Cancer Center & Research Institute

November 2014 CANCER UPDATE 7

Frank Beardell, M.D., and Donna Kerr, RN, BSN, examine a patient on the Bone Marrow Transplant Unit.

U R G E N T C A R E | The Graham Cancer Center Medical Support Unit

It is 8 a.m. Monday morning at the Helen F. Graham Cancer Center & Research Institute when Nurse Practitioner Nicole Stipo, ANP-BC, gets the call. A cancer patient with a history of cardiac problems has arrived for radiation therapy feeling short of breath.

A few minutes later and down the hall, the scene changes. Inside the Medical Support Unit, after taking an X-ray to rule out pneumonia, Stipo has administered a rescue inhaler, helping the patient breathe easier, relax and feel better.

“When patients at the Graham Cancer Center need prompt medical treatment, and their doctors are not available, we can see them at the Medical Support Unit right here in the building,” Stipo said. “We can also do CT scans and administer IV fluids if necessary.” A visit to her office helps

patients avoid the Emergency Department or even hospital admission.

Family Medicine’s Lindsey O’Donnell, M.D., collaborates as the Unit’s medical director. She sees patients on-site one afternoon a week.

“Patients who are in treatment at the Graham Cancer Center on a routine or even a daily basis have difficulty finding time to schedule appointments with their primary care doctors,” she said. “What complicates matters is that any co-morbidities they may have, such as diabetes, high blood pressure, or heart disease, may become active during their therapy for one reason or another and require our prompt attention.”

On-site Medical Support Unit helps patients avoid preventable Emergency Room visits

CONTINUED

Lindsey O’Donnell, M.D., and Nicole Stipo, ANP-BC, see patients at the Medical Support Unit

8 HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

Center for Translational Cancer Research installs Tissue Microarray technology to spur the hunt for cancer clues

I N T H E L A B | Bringing New Analysis to Different Types of Cancers

Symptoms caused by the side effects of cancer therapy can also lead patients to seek relief at the Medical Support Unit. For that reason, Stipo regularly attends one or more of the multidisciplinary cancer clinics in session weekly at the Graham Cancer Center. She works closely with the patient’s primary care doctor and cancer specialists to coordinate treatment and follow-up. If patients do not have a primary care doctor, she will try to connect them with one.

“Patients undergoing treatment for a head or neck cancer, for example, may come in for relief from mouth dryness, a sore throat or even a secondary infection that won’t wait for a visit to their doctor,” Stipo said. “Whether their need is acute or simply an annoyance, we are close by for immediate care.” ¤

The Medical Support Unit, located on the first floor, is open from 8 a.m. to 4 p.m., Monday through Thursday for patients undergoing treatment at the Helen F. Graham Cancer Center & Research Institute.

ON SITE MEDICAL SUPPORT UNIT | CONTINUED

CONTINUED

The Center for Translational Cancer Research (CTCR) at the Helen F. Graham Cancer Center & Research Institute can now produce tissue microarrays or TMAs. Picture hundreds of tiny tumor samples preserved for analysis on a single glass slide.

Funding support for installing this leading-edge technology at the CTCR comes as part of a translational research collaboration between the Graham Cancer Center and The Wistar Institute in Philadelphia.

For Senior Clinical Scientist Jennifer Sims-Mourtada, Ph.D., who is looking for markers of aggressive breast cancers, TMAs can make the process cheaper and faster. “With TMAs we can analyze hundreds of tumor markers using the same

set of specimens all at the same time,” she said. This type of rapid throughput analysis can be a game changer in the drive to translate new findings from the lab into clinical practice.

The Graham Cancer Center’s Tissue Procurement Center provides fresh tissue samples and access to several thousand banked specimens for Wistar scientists. Several Wistar scientists are collaborating with physician investigators at Christiana Care to change what we know about many different types of cancers. In addition, the Tissue Procurement Center houses thousands of paraffin wax blocks of different cancer tumor types, a valuable resource for TMA research.

„NICOLE STIPO, ANP-BC

When patients need prompt medical treatment, and their doctors are not

available, we can see them at the Medical Support

Unit right here in the building.

“

November 2014 CANCER UPDATE 9

How TMAs are produced

As a starting point, histotechnologist Marlene Goins is preparing TMAs from wax blocks of ovarian and breast tumors banked at Christiana Care.

Goins uses a fine, hollow needle to extract core samples, some as tiny as a pencil tip, and place them into a recipient wax block that can hold hundreds of samples. These can

be multiple samples from the same tumor or samples from different tumors and different donors. Researchers can request the make-up of each block according to their own study requirements, specifying the kinds of tumors, the size of each sample and the donor characteristics they need.

Once the recipient wax block is completed, Goins uses the CTCR’s newly acquired microtome to cut the block into hundreds of tissue-paper-thin slices. Each slice is a mirror grid of all the tissue cores in the original block. She affixes a single slice per glass slide, then packages the slides and sends them to the research lab for immunohistochemical and other sophisticated methods of analyses.

“There are literally hundreds of thousands of tissue samples banked at Christiana Care that we could use to produce TMAs for a multitude of research interests,” said Abraham Joseph, MA, MBA, CG, MB, DLM(ASCP), director of Molecular Diagnostics, Anatomic Pathology and Translational Cancer Research. “After 10 years, these specimens are no longer needed for diagnostic purposes, but transferring them to TMAs will preserve them as invaluable research resources.” ¤

ADVANCED TECHNOLOGY

Hundreds of tiny tumor

samples can be preserved for

analysis and can be a game

changer in translating new

findings from the lab into

clinical practice.

ABRAHAM JOSEPH, MA, MBA,

CG, MB, DLM(ASCP)

“

„

There are literally hundreds of thousands of tissue samples banked at Christiana Care that

we could use to produce TMAs for a multitude of

research interests.

Histotechnologist Marlene Goins

10 HELEN F. GRAHAM CANCER CENTER & RESEARCH INSTITUTE

Jenny Petkova, M.D., Hematologist, has broad experience in both benign and malignant blood disorders, blood banking and transfusion medicine. In July, she joined Delaware Clinical & Laboratory Physicians (DCLP), P.A., at the Graham Cancer Center. She also provides medical oversight for Christiana Care’s Blood and Bone Marrow Stem Cell Transplant Program and blood banking services. She is fellowship trained in Hematology-Oncology and Transfusion Medicine, and is excited to once again work with her fellowship mentor DCLP Hematologist Michael W. Lankiewicz, M.D. ¤

Welcome to the newest members of the Helen F. Graham Cancer Center & Research Institute

Amro H. Shihabi, D.M.D., M.D., Oral and Maxillofacial Surgeon, joined the Christiana Care Department of Oral and Maxillofacial Surgery and the Oral & Facial Surgery Faculty Practice in August. Dr. Shihabi is fellowship trained in maxillofacial oncology and microvascular reconstruction. ¤

Best practices for treating small cell lung cancer

The Graham Cancer Center is a top enroller nationally in clinical trials, which may offer the best options for treatment to qualified patients. To learn more, contact Cancer Research at 302-623-4450.

T E A M W O R K | Special is ts in your corner

Accreditation by the Commission on Cancer requires that Christiana Care’s Cancer Program perform an annual assessment of evaluation and treatment planning. For 2014, program leadership selected to evaluate the use of prophylactic brain radiation to our population of small cell lung cancer patients. Radiation may be given to the brain after other treatments to help lower the chances that the cancer will spread there. This is a recommended treatment guideline from the National Comprehensive Cancer Network (NCCN). At Christiana Care, upon chart review, 46.6 percent of the patients received prophylactic radiation. 53.3 percent of the group did not receive the treatment. Of the cases that did not follow the NCCN-recommended treatment, the vast majority of cases involved disease that was too advanced or patients who were too debilitated. In all, only 20 percent of cases did not follow the suggested NCCN treatment guidelines for reasons that are unknown. ¤

Clinical capsule

C H R I S T I A N A C A R E C A N C E R P R O G R A M 2 0 1 3 A N A L Y T I C * C A S E D I S T R I B U T I O N

YEAR CASES SEEN AT CHRISTIANA CARE HEALTH SYSTEM 2013 CASES BY AJCC STAGE GROUPS

PRIMARY SITE 2005 2006 2007 2008 2009 2010 2011 2012 2013 0 I II III IV UNK/NA

ORAL 67 51 68 73 78 87 74 82 96 2 29 10 15 33 7

Tongue 21 18 26 25 26 29 25 27 26 1 9 1 6 8 1

Mouth 36 25 29 41 45 47 34 48 62 1 20 8 6 21 6

Pharynx 10 8 13 7 7 11 15 7 8 0 0 1 3 4 0

DIGESTIVE 401 444 460 498 442 433 473 460 502 13 93 116 120 132 28

Esophagus 15 18 29 36 29 20 39 30 30 0 6 4 12 8 0

Stomach 32 35 35 34 25 32 30 36 42 1 9 4 10 14 4

Small Intestine 7 8 8 16 15 13 18 21 8 0 1 1 3 3 0

Colon 171 178 168 179 158 155 138 144 161 9 30 46 42 30 4

Rectum/Rectosigmoid 67 81 76 80 68 72 74 58 76 2 23 16 22 13 0

Liver/IHBD 21 29 35 30 32 36 36 47 46 0 8 3 10 12 13

Pancreas 63 67 69 83 77 69 85 75 90 0 10 34 10 35 1

Other Digestive 25 28 40 40 38 36 53 49 49 1 6 8 11 17 6

RESPIRATORY 452 477 439 465 446 521 469 429 470 1 129 37 107 187 9

Larynx 35 20 21 28 32 29 30 25 29 1 4 5 8 10 1

Lung 406 451 401 421 399 479 426 395 431 0 125 31 97 174 4

Mesothelioma 8 5 9 7 6 8 10 8 5 0 0 1 2 1 1

Other Respiratory 3 1 8 9 9 5 3 9 5 0 0 0 0 2 3

BONE & CONNECTIVE TISSUE 17 24 28 25 28 20 32 20 23 0 7 2 7 5 2

Bone/Joints 6 5 4 7 5 5 5 6 5 0 1 0 0 2 2

Connective/Soft Tissue 11 19 24 18 23 15 27 14 18 0 6 2 7 3 0

MELANOMA 116 121 118 145 160 136 145 108 126 21 57 21 15 5 7

Other Skin Cancer 6 7 9 13 6 7 8 13 12 0 4 1 2 0 5

BREAST 557 534 597 639 703 652 698 747 789 173 320 194 66 27 9

FEMALE ORGANS 182 194 229 198 228 202 257 252 267 3 153 22 48 31 10

Cervix 37 27 48 33 41 41 33 37 30 0 11 4 9 6 0

Uterus 98 103 113 101 110 110 154 152 157 2 108 9 20 12 6

Ovary 41 47 54 37 52 39 53 41 51 0 18 6 15 10 2

Other Female Organs 6 17 14 27 25 12 17 22 29 1 16 3 4 3 2

MALE ORGANS 328 381 407 401 302 285 225 213 218 0 63 122 14 17 2

Prostate 316 368 393 390 290 274 217 204 207 0 55 120 14 16 2

Testis 10 11 13 11 10 8 8 7 9 0 8 1 0 0 0

Other Male Organs 2 2 1 0 2 3 0 2 2 0 0 1 0 1 0

URINARY 190 179 188 179 199 215 216 216 218 75 80 19 17 22 5

Bladder 91 100 109 83 104 105 124 115 128 71 26 14 6 10 1

Kidney/Renal Pelvis 90 68 72 89 90 105 89 96 80 2 52 3 9 11 3

Other Urinary 9 11 7 7 5 5 3 5 10 2 2 2 2 1 1

BRAIN/CNS 92 116 113 123 116 112 102 106 90 0 0 0 0 0 90

ENDOCRINE 94 72 95 117 129 133 144 125 142 0 92 9 10 8 23

Thyroid 77 60 69 93 94 108 131 110 120 0 92 9 10 7 2

Endocrine/Other 17 12 26 24 35 25 13 15 22 0 0 0 0 1 21

LEUKEMIA 58 60 68 79 37 53 57 76 46 0 0 0 0 0 46

Hodgkin Lymphoma 23 18 10 20 20 25 15 9 16 0 5 4 3 4 0

Non-Hodgkin Lymphoma 96 102 102 130 126 97 108 86 97 0 22 23 17 35 0

Myeloma 18 25 26 39 28 25 28 34 36 0 0 0 0 0 36

ALL OTHER/UNDEFINED 44 58 58 74 64 79 63 64 54 0 0 0 0 0 54

TOTAL 2741 2863 3015 3218 3112 3082 3114 3048 3202 288 1054 580 441 506 333

*Analytic cases involve patients with new diagones or who were newly treated by Christiana Care Health System in 2013.

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Cancer Update is produced by Christiana Care Health System. © Christiana Care Health System, 2014. All rights reserved.

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One of the original 14 cancer centers in the nation

selected for the National Cancer Institute Community

Cancer Centers Program.

Breast Cancer

Bone Sarcoma

Genetic Risk Assessment

Genitourinary Cancer

Head & Neck Cancer/Thyroid

Hepatobiliary/Pancreatic Cancers

Lymphoma

Medical Support

Melanoma/Soft Tissue Sarcoma

Neuro/CyberKnife

Ostomy Care

Rectal/Anal Cancers

Skin Screening

Spinal Tumor & Metastatic Lesion

Thoracic/Esophageal Cancers

Young Adult Follow-up

The Multidisciplinary Cancer Centers at the Helen F. Graham Cancer Center & Research Institute offer comprehensive care and treatment.