For Referring Doctors

Text Size A A

E-Mail to a Friend






secret  Click to Play Audio


Issue 17

  • Triple Negative Breast Cancer Protocol
    Triple negative breast cancer is very difficult to treat. Read about this new trial being conducted by Jennifer Specht, MD, who hopes to give patients a breast from chemotherapy while preventing tumor growth.
  • New Patient Housing Facility at SCCA
    If you have patients coming to SCCA for long-term treatment, please refer them to SCCA House, a brand new, Built Green facility just blocks from SCCA.
  • Minimally Invasive Lung Biopsies
    Endobronchial ultrasound is now being used to guide transbronchial needle aspirations to help diagnose and stage lung cancers.
  • Surgical Management of T3 & T4 Lung Cancer
    Locally advanced lung cancers are difficult to stage which means it is also difficult to determine the best course of treatment. Douglas Wood, MD, talks about surgically managing these tumors for the best outcomes.
  • Understanding and Treating Pancreas Cancer
    It has taken 10 years, but Sunil Hingorani, MD, and his team have successfully developed a mouse model for pancreas cancer that is perfect.
  • Lymphoma Trials News
    Read the latest information about SCCA’s T-Cell Lymphoma project and the newest trials seeking patients.  

Triple Negative Breast Cancer Protocol


Breast cancer is usually subdivided based on the presence, or lack of, three “receptors” known to fuel most breast cancers: estrogen receptors, progesterone receptors, and human epidermal growth factor receptor 2 (HER2). The most successful treatments for breast cancer target these receptors, but 10 to 15 percent of women develop “triple negative” breast cancers that lack these targets. These patients with triple negative phenotype breast cancer have an aggressive disease for which successful therapy remains illusive and outcomes are often poor with standard chemotherapy.


Jennifer Specht, MD medical oncologist at Seattle Cancer Care Alliance, is the principal investigator for a phase II study of triple negative metastatic breast cancer that will evaluate the efficacy and safety of induction chemotherapy with nab-paclitaxel (Abraxane) and bevacizumab (Avastin) followed by maintenance targeted therapy with bevacizumab and erlotinib (Tarceva). The hope is to prolong progression-free survival. This study will focus on pathways for disease progression related to vascular endothelial growth factor (VEGF) and epidermal growth factor (EGFR) which are thought to be critical for triple negative breast cancer.


For reasons yet unknown, triple negative breast cancers also often over-express the protein EGFR. Inhibitors of EGFR activity have been in development for years. Although earlier compounds lacked specificity and potency, newer compounds have proven active in clinical studies. In lung cancers, the use of erlotinib has proven to be a successful targeted therapy that stops the production of this protein. Specht hopes to show that this drug will be successful with triple negative breast cancer patients as well.

“We hope this treatment will allow women to have a break from chemotherapy and prevent tumor growth by targeting these two important biologic pathways,” Specht says.

 

Eligibility. This is a phase II study. All patients will receive active treatment. There will be no placebo. All patients must have a new recurrence of triple negative breast cancer with either measurable disease or non-measurable disease and an elevated tumor marker. Patients should be at least 12 months from previous weekly neoadjuvant or adjuvant paclitaxel. Patients are needed to complete the study which is open at Skagit Valley Regional Cancer Care Center, Cascade Cancer Center, Multicare Health System, and Wenatchee Valley Medical Center, Providence Alaska, and Overlake Hospital Medical Center. If you would like this study to be available for your patients at your institution, please contact Tove Thompson at tovethom@seattlecca.org or by calling (206) 288-1233.


Contact Tracy Headley, SCCA breast cancer patient care coordinator, to refer a patient for treatment at SCCA at theadley@seattlecca.org or by calling (206) 288-2166.

 


New Patient Housing Facility at SCCA


SCCA House is an 80-unit patient housing facility for cancer patients and their families and caregivers.Located in the South Lake Union neighborhood of Seattle, SCCA House is a “home away from home” for general oncology and post-stem cell transplant patients. The carefully monitored clean environment is designed for patients with some degree of immunosuppression.

 

“This beautiful new facility will help fill a significant demand for lodging for patients and their caregivers during various forms of cancer treatment, which can last as long as several weeks,” said Norm Hubbard, SCCA executive vice president.

 

Local hotels have been the only other choice for out-of-town patients aside from the 70-unit Pete Gross House, which primarily serves patients who are undergoing stem cell transplants at SCCA. The Pete Gross House has a large waiting list because the highly regarded transplantation program draws patients nationally and internationally. Transplant treatment typically lasts several months.

 

SCCA House has 80 private suites with kitchenettes (equipped with microwave, small fridge, and sink) are geared to those needing to stay a few nights to a few weeks. The rooms vary in size to

accommodate two, three, or five persons and include many special features and amenities. 

 

For more details about SCCA House or to make reservations, call (206) 204-3700 or visit the web at www.seattlecca.org.

 


Minimally Invasive Lung Biopsies

 

By Jason Chien, MD, Associate Professor of Pulmonary and Critical Care Medicine at the University of Washington and Director of the Lung Cancer Early Detection and Prevention Clinic at SCCA.


Early diagnosis and staging of lung cancer is the most important step toward definitive treatment for lung cancer.  Pulmonologists at Seattle Cancer Care Alliance now use a minimally invasive procedure called endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) in their array of approaches for diagnosing and staging lung cancer.


Early diagnosis and staging of lung cancer is the most important step toward definitive treatment for lung cancer. The pulmonologists at SCCA’s Lung Cancer Early Detection and Prevention Clinic (LCEDPC) now use a minimally invasive procedure called endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) in their array of approaches for diagnosing and staging lung cancer.


Prospective multicenter trials in patients with known or suspected lung cancer indicate that the sensitivity is generally higher than 90 percent.  Among patients with lung cancer and a radiographically normal mediastinum (node size range, 5 to 10 mm), the sensitivity, specificity, and negative predictive values are 92.3, 100, and 96.3 percents respectively.  When compared to patients with both negative CT scan findings and no detectable PET scan activity in the mediastinum, the reported sensitivity approaches 90 percent, and the study revealed un unexpected 9 percent prevalence of mediastinal metastasis, suggesting that EBUS-TBNA is a useful preoperative staging tool in all patients with lung cancer who are being considered for surgery.

 

EBUS-guided TBNAs have several advantages. It is performed as an outpatient procedure, requiring only conscious sedation with a short recovery time. EBUS is able to reach more lymph node stations in the mediastinum, including the paratracheal and carinal nodal stations, and the hilar and subhilar stations. And, EBUS is associated with minimal adverse events. In the published literature, EBUS has been performed thousands of times with no serious complications reported. Because this is a minimally invasive approach, EBUS is the procedure of choice for patients who may have scar tissue in the mediastinum from previous surgery. 

 

“This minimally invasive procedure has revolutionized the way pulmonologists approach mediastinal adenopathy and lung cancer,” says Dr. Jason Chien, director of the SCCA LCEDPC. Around the world, EBUS is rapidly replacing surgical mediastinoscopy as the preferred procedure for biopsy of mediastinal lymph nodes and staging of lung cancer. 


If you would like more information on this procedure, or would like to have your patient evaluated for this procedure, please contact Donna Manders, LCEDPC coordinator, at (206) 288-7620.

 


Surgical Management of T3, T4 Lung Cancer

 

By Douglas E. Wood, MD, Professor and Chief, Division of Cardiothoracic Surgery Endowed chair in Lung Cancer Research, University of Washington


Locally advanced lung cancer, where the primary tumor is close to the carina, invading the chest wall or diaphragm (T3), or has invaded adjacent structures or organs (T4), creates significant difficulties in staging and determining optimal therapy.
 

Historically, involvement of adjacent structures confers a T3 status when these structures are resectable (chest wall, superior sulcus, diaphragm, pericardium), while T4 tumors have typically been considered unresectable, although this has been challenged by advancing surgical techniques and validated by current revisions in the lung cancer staging system.

 

When surgical treatment results in total removal of the primary tumor and involved lymph nodes, there is still a reasonable chance for cure, even in locally advanced cancers.  Although both T3 and T4 disease may now be resectable for curative intent within locally advanced disease there is a wide spectrum of biologic behavior represented by the degree of lymph node involvement which is a strong surrogate for distant metastatic disease. 

 

Although T3N0 tumors can be resected with a five-year survival of 50 percent or greater, five-year survival in patients undergoing resection of T3N2 tumors is negligible. T4N0 tumors are certainly not biologically the same as T1-T4N3 tumors, and by definition, are tumors with less propensity to metastasize. T4N3 disease has a negligible opportunity for surgical cure, but the subset of T4N0 patients who can be completely resected by current surgical techniques have a legitimate possibility of prolonged survival.  For this reason, the 7th edition of the lung cancer staging system has downstaged T4N0-1 to Stage IIIA, rather than Stage IIIB, implying the potential for curative intent therapy with surgery or with multimodality therapy. This differentiation of T4N0 disease has long been recognized in large volume thoracic surgery centers where more complex lung cancer resections are performed, and is also acknowledged in major lung cancer guidelines published by the National Comprehensive Cancer Network and American College of Chest Physicians.

 

Surgical resection remains an important option for patients with locally advanced lung cancer and can be performed with acceptable postoperative morbidity and mortality.  Preoperative imaging is often inaccurate in determining advanced T stage and should not be considered a contraindication to resection in the absence of consultation with an experienced thoracic surgical oncologist. The ability to accomplish a complete surgical resection along with lymph node status are the primary prognostic factors in considering extended resections for T3 or T4 tumors. It is important that a thoracic surgical oncologist be a primary component of the multi-modality team making staging and treatment recommendations.  Modern techniques of chest wall resection and reconstruction and bronchoplastic procedures allow complete resection of locally advanced tumors with favorable five-year survival and low morbidity and mortality.  Bronchoplastic procedures provide the advantage of allowing resection of central lung cancers, even in patients with poor pulmonary function, but have added benefit of decreasing operative morbidity and mortality and improving long-term function and quality of life in patients who would have otherwise required a pneumonectomy or palliative chemoradiation. The role of neoadjuvant or novel and conventional adjuvant therapies is unclear for these locally advanced tumors. 

 


Understanding and Treating Pancreas Cancer


With a very systematic 10-year plan, Dr. Sunil Hingorani, director of the Pancreas Cancer Specialty Clinic at SCCA, and his team developed a mouse model that is 100 percent accurate to capitulate pancreas disease. Dr. Hingorani specializes in pancreas cancer, considered one of the most lethal human cancers. Difficult to detect because of vague symptoms, pancreas cancer becomes invasive quickly and doctors cannot safely biopsy the pancreas, which makes it nearly impossible to study. With no feasible way to obtain samples from early stage disease, researchers can not observe the progression of pancreas cancer in humans the way they can with other cancers.

 

To overcome this hurdle, Dr. Hingorani created the first replica of human pancreas cancer in mice. This model is arguably the most accurate of any human cancer and recreates the same genetic changes that both initiate the cancer and accumulate naturally as the disease progresses. The same progression of clinical symptoms and even the same response (or lack of response) to treatments that human patients receive are seen in this mouse model. This achievement provides researchers with a way of studying the disease’s development and provides an avenue for testing new prevention, detection, and treatment strategies.

 

In 2006, Dr. Hingorani and his team discovered that distinct genetic routes exist to pancreas cancer, with unique histological and clinical behaviors.

 

In 2007, he discovered the specific sequence of genetic changes that determines the development of either a deadly or a more curable form of pancreas cancer. Eventually his work could lead to new ways to improve treatment and survival.

 

In 2008, a multicenter team of researchers led by Fred Hutchinson Cancer Research Center researcher Samir Hanash, MD, identified for the first time a panel of proteins linked to the early development of pancreas cancer in mice that also applies to early stages of the disease in humans. This breakthrough brought scientists a significant step closer to developing a blood test to detect pancreas cancer early, when cure rates are highest.

 

In 2009, an international team of investigators, including Hingorani, discovered a mechanism that may explain why pancreas cancer patients are often resistant to common chemotherapy treatment. The group found that pancreas cancer may be resistant to chemotherapy because the tumors have poor networks of blood vessels, which makes it harder for drugs to reach the tumor. The results of this study should help scientists overcome this drug resistance and develop new, more effective treatments in the future.

 

SCCA’s Pancreas Cancer Specialty Clinic (PCSC) hopes to define a new standard of care for pancreas cancer while minimizing the obstacles that patients and their families may encounter in navigating a complex medical system.  The PCSC is comprised of a dedicated team of nurses, symptom

management and pain specialists, nutritionists, physical therapists, social workers, radiologists, and surgical, medical and radiation oncologists all singularly devoted to the clinic’s mission. To refer your patient to the PCSC, call (206) 288-7222.

 


Lymphoma Trials News


It was just one year ago that Dr. Andrei Shustov, hematologist at Seattle Cancer Care Alliance, announced a new T-Cell Lymphoma Project at SCCA. The T-cell project has grown exponentially since January 2009 and involves collaborative efforts between research and several clinical studies for peripheral (systemic) and cutaneous T-cell lymphomas in general as well as specific subtypes, bringing focus to a challenging disease.

 

“We now see 70 to 80 patients a year at SCCA referred to us from five states which will help us improve quality of care and provide early access to expert opinions and novel/experimental therapies for this very challenging type of lymphoma,” says Shustov. 
 
Positive results from the PROPEL Study (UW #6398) that studied relapsed and refractory peripheral T-cell lymphomas led the U.S. Food & Drug Administration to approve pralatrexate (the study drug) in September 2009.
 
Results from a Phase II, multicenter, open-label trial evaluating the activity and tolerability of romidepsin (depsipeptide, FK228) (SCCA trial #20070025) in progressive or relapsed peripheral T-Cell lymphoma following prior systemic therapy will be reported at the June 2010 American Society of Clinical Oncology (ASCO) meeting. 
 
Several new studies are accruing patients currently: 
The successor to PROPEL, a phase I-II prospective trial of pralatrexate and gemcitabine combination, is accruing patients with relapsed and refractory B- and T-cell lymphomas, including Hodgkin’s Lymphoma.
 
A Phase II registrational study (#20081708) is activated at SCCA using SGN-35, a monoclonal antibody linked to a toxin, for the treatment of a specific subtype of T-cell lymphomas, anaplastic large cell lymphoma (ALCL). Preliminary results are very encouraging in both Hodgkin’s lymphoma and ALCL. 

A Phase II prospective non-randomized two-arm clinical trial (#6914) of dose-adjusted schedule of Vorinostat is accruing patients who have primary cutaneous T-cell lymphoma (CTCL), such as mycosis fungoides, who have not received prior systemic therapy.
 
The lymphoma team expects a trial of belinostat (next generation histone deacetylase inhibitor) to begin accruing in early 2010 to replace the above romidepsin trial.
 
If you have patients that might benefit from one of these trials, contact Fereshteh Assadian, study coordinator at (206) 667-7540. Contact Dr. Shustov through UW MedCon Service for clinical questions about your T-cell lymphoma patients.

 


Adult Bone Marrow Transplant News

The SCCA Adult Bone Marrow Transplant News is a publication presenting the latest information on bone marrow transplant research at SCCA, providing up-to-date information for all health care professionals caring for transplant patients.

Pediatric Bone Marrow Transplant News

Read about important outcomes research at the Hutchinson Center that may benefit your patients.

Clinical Trials Monthly

Each issue of Clinical Trials Monthly highlights several of the more than 200 clinical trials that are currently recruiting patients at SCCA.

The Leading Edge Newsletter

Each quarterly Leading Edge newsletter will highlight a new topic to give you the latest news on leading-edge therapies that SCCA physicians are offering.