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SCCA Network News, Issue 17 Winter 2013

In this issue:

Happy New Year!

It seems like we were just here – starting 2012, but every year we say how fast the year goes by and 2012 was not any different. To recap our Network 2012 year, below is a small sampling of our collaborative projects and activities:

  • Celebrated our 10-year affiliation anniversary with Olympic Medical Center in August 2012.
  • Launched our network-wide clinical performance program using nationally approved quality metrics. We are currently piloting Phase II of this program including lung metrics.
  • Moved the PET imaging cross-calibration project into its Phase II with network participants.
  • Bozeman, MultiCare, and Wenatchee qualified to be the first affiliate sites to participate with our NCCN research project. As this effort matures, there will be additional opportunities for our other sites to participate.
  • Launched the Culture of Research initiative launched at the Network Summit in June 2013.
  • Columbia Basin Hematology and Oncology became a Network member in January 2012.
  • Overlake Hospital Medical Center left the Network family in September due to corporate structure changes.

New initiatives, activities, and projects to watch throughout 2013:

  • Adopting the ASCO Choosing Wisely® campaign into oncology practice in SCCA Network Puget Sound sites.
  • Working with our Network providers to improve our referring provider communication process.
  • Considering adding two new Network members before the end of the year.

We want to acknowledge all of you for your dedication and commitment to providing the very best care for our patients. It is sometimes daunting to think about the many changes and demands we all face, but at the end of the day, the true question we must answer is whether we have provided and done all we can for our patients and their families. Thank you for all that you do.

Proton Therapy for Prostate Cancer: New Opportunities and Challenges

By Jay J. Liao
More than 200,000 patients are diagnosed with prostate cancer each year in the United States. There have been significant advances in surgical techniques, radiation therapy, and systemic therapy that have led to improved outcomes. Despite this, approximately 27,000 patients die of prostate each year in our country. Our goals are to improve the cure rates in patients with more aggressive disease and maintain the excellent outcomes in patients with more favorable disease while reducing treatment side effects and improving quality of life. Advances in radiotherapy will likely play an important role in achieving these aims.

Seattle Cancer Care Alliance established a partnership with ProCure to build the first proton therapy center in the Pacific Northwest. The center, located on the campus of Northwest Hospital & Medical Center in Seattle, broke ground in January 2011 and is anticipated to begin treating patients in March 2013. At capacity, it will accommodate approximately 1,400 patients a year. There is active investigation nationally and internationally on the potential advantages of proton therapy in a broad range of tumor types including prostate, brain, central nervous system, head and neck, lung, gastrointestinal, sarcomas, and pediatric cancers. We are excited about its potential in the treatment of prostate cancer.

Historical perspective

Most therapeutic radiation therapy is delivered using medical linear accelerators, or linacs, which generate high-energy X-rays. Early approaches used simple two-dimensional planning to treat a “box-shaped” volume around the prostate. With the advent of CT imaging, three-dimensional conformal radiation therapy (3D-CRT) became possible, which uses a greater number of and more customized radiation fields. 3D-CRT allowed higher radiation doses to be delivered safely to the prostate, which sits in close relationship to the bladder and rectum. This “dose escalation” resulted in improved tumor control outcomes across multiple prospective clinical trials.1,2

Improvements in both computer planning and linac technology led to intensity-modulated radiotherapy (IMRT). IMRT uses more complex radiation beam shaping with sophisticated computerized algorithms to deliver even more tightly shaped radiation dose distributions, albeit at the cost of irradiating surrounding normal tissue to lower radiation doses. IMRT provides superior sparing of the bladder and rectum compared to 3D-CRT and has generally been accepted as the standard approach to facilitate dose escalation while minimizing the risk of complications.3 Most centers now utilize some form of image guidance to deliver IMRT. Image-guided radiotherapy or IGRT refers to various technologies used to precisely verify alignment of the prostate before or during daily treatment, typically using imaging or implanted intraprostatic markers.

Heavy particle therapy, which includes protons, neutrons, and carbon ions, has unique physical and biological properties. Particle therapy is actually not entirely new. In the 1980s and 1990s, there was active clinical investigation in fast neutron therapy, which has biologic advantages in terms of tumor cell kill compared to X-rays. The University of Washington (UW) helped lead numerous clinical trials across many cancers, including prostate cancer. Studies in locally advanced prostate cancer indicated improved loco-regional control with neutrons compared to X-rays; however, increased rectal and bowel toxicity prohibited the adoption of neutron therapy as the new standard for prostate cancer.4,5 Studies in other tumor sites did demonstrate that neutrons were superior with acceptable side effects, and it continues to be used for these indications today.

Proton therapy

Proton therapy has been in clinical use since the 1970s in the United States. The first facilities were built in Boston, Mass. and Loma Linda, Calif. High-energy proton beams are generated with large particle accelerators, either cyclotrons or synchrotrons. The significant size and cost of proton treatment facilities has limited the availability of this technology. However, we are now in the midst of a period of major expansion of this treatment, with about 10 active centers in the United States and more than 40 worldwide. The physical aspects of a proton beam’s radiation dose deposition are significantly different than with X-rays. With X-rays, shaped dose distributions are generated by using many convergent radiation beams that enter and exit through adjacent normal tissues, effectively spreading out the dose. With protons, due to their electrical charge and higher mass, there is reduced side scatter of the beam and little energy deposition as the beam enters tissue until near the end of its path. After a sharp maximum point, called the Bragg peak, the beam essentially stops with almost no exit dose into the normal tissue beyond. As a result, proton radiation may be delivered using relatively few beams, while significantly limiting doses to surrounding normal tissues. This may reduce the risk of bladder and rectal complications as well as the risk of late radiation-induced secondary cancers. A dose comparison of protons compared to X-ray therapy with IMRT is shown in the figure below.

Clinical data and research opportunities

To date, more than 40,000 patients world-wide have been treated with proton therapy across a range of tumor types. Approximately 2,000 prostate cancer patients have been treated with protons, as reported in the medical literature. Studies to date have demonstrated that proton therapy alone or combined with X-ray therapy can facilitate dose escalation to the prostate with excellent rates of biochemical and local control and a very low risk of genitourinary or gastrointestinal complications.6-8

Numerous single-arm and randomized clinical trials are now being conducted to further define the role of proton therapy. The UW/SCCA is involved in the Proton Therapy Collaborative Group (PCG), which is designing multicenter proton clinical trials. In patients with favorable disease, protons may provide a means of safely reducing the length of the treatment course while maintaining excellent cure rates. In patients with more unfavorable disease, protons may facilitate novel dose escalation strategies or allow more effective systemic therapies to be combined with radiation without increasing toxicity. In addition to cancer control outcomes, comparative quality of life outcomes will be important to evaluate, including impact on urinary, bowel, and sexual function. Some intriguing recent studies have reported an extremely high rate of erectile function preservation in younger patients (< 60) undergoing proton therapy that compares very favorably with any reported modern surgical or conventional radiotherapy series.9

Some of the proton clinical trials that are being designed or have recently opened:

  • A randomized trial of IMRT versus proton therapy for low and low intermediate risk disease is accruing patients (MGH / University of Pennsylvania).
  • Role of hypofractionation (fewer, higher dose treatments): A randomized trial of standard fractionated (8 weeks) versus hypofractionated (5 treatments over 1 to 2 weeks) proton therapy for low-risk disease (PCG).
  • A randomized trial of moderately hypofractionated (5.5 weeks) proton therapy with or without six months of androgen deprivation therapy for intermediate-risk disease.
  • Addition of systemic agents including chemotherapy (taxane-based) or novel therapeutics to proton therapy in high-risk localized disease.
  • Dose-escalated pelvic nodal radiation with protons for patients with node-positive or nodenegative, high-risk localized disease.
  • Postoperative or salvage radiotherapy with protons following radical prostatectomy, including the feasibility of dose escalation to the prostate fossa.

We encourage the enrollment of patients on prospective clinical trials such as these, a number of which will be open at UW/SCCA. Advances in treatment, including proton therapy, may allow us to cure more patients with prostate cancer while improving the quality of life of our patients. Announcements for new proton clinical trials will be published in the Clinical Trials Monthly newsletter at www.seattlecca.org/clinical-trialsmonthly.cfm. (References are available online at www. seattlecca.org/newsletters/the-leadingedge-issue-26.cfm).

Providence Alaska Medical Center

Roy Olpin, MBA, MPH, FACHE, CQIA, has joined Providence Alaska Medical Center as director of the Providence Cancer Center, responsible for the oncology service line.

Olpin comes to Providence after working as regional vice president of oncology for Sarah Cannon Cancer Services with Hospital Corporation of America in Denver, Colo. His prior work experience includes senior director of oncology services at Providence Regional Cancer System in Olympia, Wash., and a series of roles at the University of Texas MD Anderson Cancer Center in Houston, Texas.

Olpin earned a bachelor of science degree in international business management from Johnson & Wales University in Providence, R.I., and dual master’s degrees in public health and business administration from Boston University. He also has earned a certified quality improvement associate designation from the American Society for Quality and is a fellow in the American College of HealthCare Executives.

“We are privileged to have Roy join the Providence team,” says Richard Mandsager, MD, chief executive of Providence Alaska Medical Center. “He has previous experience as a person of Providence and a passion for service in not for- profit healthcare.”

Clinical Research Update

Thinking back to the Network Summit in June 2012, you may remember a presentation on the culture of research. As announced at the Summit, using the ASCO article “Attributes of Exemplary Clinical Trial Sites” as our starting point, Cecelia Zapata, Benjamin Greer, MD, and Tove Thompson will be visiting each Network member institution in 2013 to work through the attributes and identify areas for improvement. We look forward to this work and hope it will make both our office and your institutions better clinical trial sites.

The goals of this project are to:

  • Increase availability of appropriate clinical trials
  • Boost enrollment to meet the American College of Surgeons Commission on Cancer’s new, higher standards
  • Optimize enrollment to studies offered through the SCCA Network office
  • Assure efficient and impeccable study implementation and timely data abstraction

We will be looking to each Network member to identify areas of need related to study implementation. Member institutions that have completed this process with us have identified the following focus areas:

  1. Developing a more rapid study-review process
  2. Developing a research relationship with Laboratory Medicine for processing of research samples
  3. Mapping out research processes from study identification through study close-out
  4. Developing a process for tracking research budgets, including a process for assuring that patient care procedures done for research purposes are billed to the study budget.

If we have not already visited your cancer center, please expect a call from our office during the next month to identify a date and time for this meeting.

Trials now open

  • Celgene 7755: A Phase II Study of Weekly Abraxane® (nab-paclitaxel) for Patients with Advanced NSCLC with EGFR Mutations Following Front-Line Therapy with EGFR Tyrosine Kinase Inhibitors (Participating Network Member Institutions: Bozeman Deaconess Hospital, Group Health Cooperative, MultiCare Health System, Olympic Medical Center, Skagit Valley Hospital)
  • Endocyte EC-FV-06: A Randomized, Double- Blind Phase III Trial Comparing EC145 and Pegylated Liposomal Doxorubicin (PLD/ Doxil®/Caelyx®) in Combination Versus PLD in Subjects with Platinum-Resistant Ovarian Cancer (Participating Network Member Institutions: Bozeman Deaconess Hospital, Group Health Cooperative, MultiCare Health System)
  • Esperance ACT 12601: A Novel LHRH Receptor-Targeted, Membrane-Disrupting Peptide, Plus Paclitaxel Versus Paclitaxel Alone for Refractory or Recurrent Ovarian Cancer: A Phase II, Randomized, Multicenter Trial (Participating Network Member Institutions: Bozeman Deaconess Hospital, Columbia Basin Hematology and Oncology, Group Health Cooperative, MultiCare Health System, Skagit Valley Hospital, Wenatchee Valley Medical Center)
  • Bionomics GU09-145: Phase I/II Study of BNC105P in Combination with Everolimus or Following Everolimus for Progressive Metastatic Clear Cell Renal Cell Carcinoma Following Prior Tyrosine Kinase Inhibitors (Participating Network Member Institutions: Bozeman Deaconess Hospital, Columbia Basin Hematology and Oncology, Group Health Cooperative, Olympic Medical Center)

Trials opening soon

  • Nordion TS-102: A Phase III Clinical Trial Evaluating TheraSphere® in Patients with Metastatic Colorectal Carcinoma of the Liver Who Have Failed First Line Chemotherapy (Participating Network Member Institutions: Group Health Cooperative, Olympic Medical Center, Skagit Valley Hospital)
  • Spectrum SPI-ZEV-11-301: A Phase III, Open-Label, Multicenter, Randomized Study of Sequential Zevalin (ibritumomab tiuxetan) Versus Observation in Patients at Least 60 Years of Age with Newly Diagnosed Diffuse Large B-cell Lymphoma in PET-Negative Complete Remission After R-CHOP or R-CHOP-Like Therapy (ZEAL) (Participating Network Member Institutions: Columbia Basin Hematology and Oncology, Group Health Cooperative, MultiCare Health System, Skagit Valley Hospital)

SCCA Physician Profile: Jay J. Liao, MD

Jay J. Liao, MD, is an assistant professor of Radiation Oncology at the University of Washington School of Medicine. His clinical expertise is in the treatment of head and neck cancers, salivary gland tumors, skin cancer including melanoma and Merkel cell carcinoma, and genitourinary tumors.

He received his medical degree at the University of Michigan Medical School in Ann Arbor, Mich., and completed his residency in radiation oncology at Georgetown University in Washington, DC. Liao’s clinical research interests are in the management of head and neck cancers including conformal radiotherapy techniques, IMRT, image-guided radiotherapy, fast neutron radiotherapy, and functional imaging. He is involved in clinical trials for patients with head and neck cancers and prostate cancer at SCCA.

Network in the Community

The 2012 Cancer Support Community (CSC) Gala was held on Saturday, Oct. 20 at the Hilton Garden Inn in Bozeman, Mont. The theme this year was “Hollywood Through the Ages,” and it was a true celebration. The evening included dinner, music, friends, and live and silent auctions that raised funds to provide improved quality of life for people with cancer.

CSC supports patients of the Bozeman Deaconess Cancer Center (BDCC) by providing more than 50 free monthly support groups, education sessions, family support services, mind/body enrichment activities, and social activities including cooking and yoga classes. The SCCA Network and BDCC supported this event by providing custom co-branded etched martini glasses to guests. Also on Oct. 20, Olympic Medical Center (OMC) hosted its 10th annual Harvest of Hope Gala. This year’s theme was a tour of South Africa’s celebrated wine country. Chef Kathryn Kitts of The Sweet Beginnings Café in Sequim created a delicious menu consisting of South African dishes. Congratulations to OMC for breaking previous fundraising records.