Issue 26Fall 2012
- Proton Therapy for Prostate Cancer: New Opportunities and Challenges
- Esophageal Cancer: Early Diagnosis and Specialized Surgeries Can Improve Outcomes
- Esophageal Cancer: A Moving Target, an Opportunity
- Robotic Surgery for Endometrial Cancer--And Survivors' Obesity -Related Risks
- Non-Invasive Screening Test Could Replace Colonoscopy
- Pretargeted Radioimmunotherapy: a New, Improved Way to Treat Leukemia
- Introducing Gabriela Chiorean, MD, specialist in treating pancreatic, gastrointestinal, and hepatobiliary cancers.
By Jay J. Liao, MD
Over 200,000 patients are diagnosed with prostate cancer each year in the U.S. 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 each year of prostate cancer in the U.S. 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.
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, 3-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 to 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 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 has been in clinical use since the 1970s in the U.S. 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 U.S. and over 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 Figure 1.
Clinical data and research opportunities
To date, over 40,000 patients have been treated with proton therapy worldwide 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 either 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) that 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 proton clinical trials that are being designed or have recently opened:
- A randomized trial of IMRT versus proton therapy for low and lowintermediate 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 node-negative, high-risk localized disease.
- Postoperative or salvage radiotherapy with protons following radical prostatectomy, including the feasibility of dose escalation to the prostate fossa.
1. Kuban DA, Tucker SL, Dong L, et al. Long-term results of the M. D. Anderson randomized dose-escalation trial for prostate cancer. International journal of radiation oncology, biology, physics 2008;70(1): 67-74.
2. Peeters ST, Heemsbergen WD, Koper PC, et al. Dose-response in radiotherapy for localized prostate cancer: results of the Dutch multicenter randomized phase III trial comparing 68 Gy of radiotherapy with 78 Gy. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2006;24(13): 1990-6.
3. Zelefsky MJ, Levin EJ, Hunt M, et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. International journal of radiation oncology, biology, physics 2008;70(4): 1124-9.
4. Russell KJ, Caplan RJ, Laramore GE, et al. Photon versus fast neutron external beam radiotherapy in the treatment of locally advanced prostate cancer: results of a randomized prospective trial. International journal of radiation oncology, biology, physics 1994;28(1): 47-54.
5. Laramore GE, Krall JM, Thomas FJ, et al. Fast neutron radiotherapy for locally advanced prostate cancer. Final report of Radiation Therapy Oncology Group randomized clinical trial. Am J Clin Oncol 1993;16(2): 164-7.
6. Slater JD, Rossi CJ, Jr., Yonemoto LT, et al. Proton therapy for prostate cancer: the initial Loma Linda University experience. International journal of radiation oncology, biology, physics 2004;59(2): 348-52.
7. Shipley WU, Verhey LJ, Munzenrider JE, et al. Advanced prostate cancer: the results of a randomized comparative trial of high dose irradiation boosting with conformal protons compared with conventional dose irradiation using photons alone. International journal of radiation oncology, biology, physics 1995;32(1): 3-12.
8. Zietman AL, Bae K, Slater JD, et al. Randomized trial comparing conventional-dose with high-dose conformal radiation therapy in early-stage adenocarcinoma of the prostate: long-term results from proton radiation oncology group/american college of radiology 95-09. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2010;28(7): 1106-11.
9. Hoppe BS, Nichols RC, Henderson RH, et al. Erectile function, incontinence, and other quality of life outcomes following proton therapy for prostate cancer in men 60 years old and younger. Cancer 2012;118(18): 4619-
By Paul Courter, Science Writer
Cancers of the esophagus and esophagogastric junction remain notoriously difficult to treat. Overall long-term survival rates are still poor. New targeted treatments, thus far, show only hints of benefit. And open surgical resection of the esophagus—hidden deep in the chest cavity and surrounded by the heart, aorta, and lungs—is still one of the most complicated, risky, and morbid operations performed in the gastrointestinal tract.
But outcomes may finally be improving for those patients—over 17,000 per year in the U.S.—who are newly diagnosed with esophageal cancer. “A decade or two ago,” says Brant K. Oelschlager, MD, a surgeon at UW Medicine who specializes in esophageal and gastric surgery, “a diagnosis of esophageal cancer was less common and thought to be a death sentence.”
“Today,” he says, “we are seeing more of these patients and seeing them earlier, which is critical, and we also have new minimally invasive techniques, better perioperative management, and improved neoadjuvant therapy.”
New evidence shows value of minimally invasive surgery
A recent study published by Oelschlager and his colleagues at University of Washington Medical Center documents a 63 percent 5-year survival in 72 patients with esophageal cancer who underwent a special hybrid laparoscopic-assisted transhiatal esophagectomy; this survival rate is
substantially higher than most outcomes previously reported with traditional open procedures. [Montenovo et al. Dis Esophagus 2011;24:430-436]
While not all patients are candidates for minimally invasive surgery, surgeons at UW Medicine will be able to determine the best options for individual patients. To achieve such improved outcomes, Oelschlager recommends that patients be sent to an esophageal specialty center like SCCA—not only because a team of experts is needed to design and manage the increasingly complicated treatment algorithms but also because of the inherently complex and risky nature of the surgery. These challenges, he says, mandate care by a large multidisciplinary team that includes a surgeon who is highly experienced in techniques for the esophagus.
Why minimally invasive surgery makes a difference
Today at SCCA, almost all esophagectomies (in which portions of the esophagus and nearby lymph nodes are removed) are done using laparoscopic or minimally invasive techniques. By accessing the esophagus from below the diaphragm rather than via the chest as in the traditional open procedure, many morbidities associated with breaking ribs and deflating lungs are avoided. Key advantages of the less invasive approach include less blood loss, shorter intensive care unit and hospital stays, less pain and discomfort, fewer pulmonary complications, and a speedier recovery. By helping patients get back on their feet sooner, the less invasive surgical approach also opens the door to another major benefit: patients can begin post-op chemotherapy or radiation treatments sooner. Initiating post-surgical medical treatment earlier—often by as much as two weeks—tips the scales even more toward better outcomes.
For many procedures, the new laparoscopic approach may also enhance the surgeon’s technique. “We can achieve better visualization with two times magnification of the organs and the lymph nodes,” says Oelschlager. “This actually allows greater precision, less bleeding, and finer margins.” In some cases—as in the study mentioned above—the minimally invasive approach can be combined with an abbreviated open procedure to ensure complete lymph node harvest while also limiting the overall time of the operation.
The exact operative approach selected for any patient will be dictated by tumor location, surgical goals (e.g., curative or palliative), and patient factors such as weight and general health. The surgeon’s experience is also key. Oelschlager, who performs about 60 or 70 resections of the esophagus or stomach each year, is one of the country’s leading experts in minimally invasive techniques for the foregut. Over the last 15 years, he and Carlos A. Pellegrini, MD, chair and professor of surgery at UW, have pioneered many innovative minimally invasive approaches for management of upper gastrointestinal cancers. Together at UW’s Center for Esophageal & Gastric Surgery, Oelschlager and Pelligrini average more than 400 complex operations on the esophagus or stomach every year. When an approach through the chest is necessary, they work with an exceptional group of thoracic surgeons to provide the right approach for the right patient. This team approach is essential.
To refer your patient to the Esophageal & Gastric Surgery Center, call 206-288-SCCA (7222) or go online to https://www.seattlecca.org/physician-referral.cfm
By Paul Courter, Science Writer
Over the past 20 years, the incidence of esophageal cancer has risen throughout the U.S. The rise is associated with a generational shift in tumor type and location, from squamous cell carcinomas in the more proximal esophagus to adenocarcinomas in the lower esophagus or the
The surge in distal adenocarcinomas is linked to the epidemic of gastroesophageal reflux disease (GERD), which in turn is related to higher rates of obesity. Meanwhile, the main risk factors for squamous cell carcinoma—tobacco, alcohol, and poor diet—have generally diminished in the U.S. population.
While certainly not good news, the shift to adenocarcinoma has at least given primary care physicians and gastroenterologists a better opportunity to detect early signs of esophageal cancer. In particular, in patients with Barrett’s esophagus (a mutation of the esophageal lining due to GERD), regular surveillance can identify those who may benefit from stepped-up acid-lowering therapy or localized endoscopic mucosal resection. And in those screened patients who have already transitioned to early-stage cancers, referral for prompt minimally invasive esophagectomy can lead to higher survival rates than surgery in those who are referred with later-stage symptomatic disease.
Clearly, aggressive follow-up of patients with Barrett’s esophagus is essential in identifying and referring those patients who have a chance of cure.
A multidisciplinary team focused on esophageal care
Surgery alone is typically not enough to deal with esophageal cancer. Chemotherapy and targeted radiation, which have both become more effective and less toxic in recent years, are often used before or after surgery to manage the disease. For unresectable disease, procedures to
relieve obstructions and help patients eat and feel more comfortable are also critical.
At SCCA, a whole team of medical oncologists, radiation oncologists, gastroenterologists, pathologists, nurses, nutritionists, and others with special experience with esophageal and gastric cancer work with surgeons to design a long-term treatment plan that follows the best available
evidence and also makes sense for the patient.
“We have everything the patient needs right here,” says Oelschlager. “Our team has extensive experience in esophageal and gastric cancers. We ensure patients receive all the latest, most effective, and most tolerable therapies. We provide outstanding supportive care and access to clinical trials with novel agents. All that highly specialized medical and surgical experience is here in one clinic for the patient.”
To make an appointment for your esophageal cancer patient at SCCA, call (206) 288-7222 or refer them online at www.seattlecca.org/physician-referral.cfm.
By Laurie Fronek, Medical Writer
The vast majority of endometrial cancers are cured with surgery alone or surgery combined with chemotherapy or radiation. But for many survivors, being cancer-free doesn’t mean they’re entirely out of the woods.
Easier, more precise dissections with da Vinci
About 75 to 80 percent of hysterectomies for SCCA patients with endometrial cancer are now done using the state-of-the-art da Vinci surgical system, compared with 10 to 15 percent of such surgeries only five years ago. The robot allows surgeons to do very technically challenging moves.
“We can perform the difficult and fine dissections required with cancer much more easily and precisely with the robot than with non-robotic laparoscopic methods,” explains Barbara A. Goff, MD, professor of gynecologic oncology at University of Washington School of Medicine.
“With the robot, visualization and magnification are greatly enhanced, and the instruments are wristed, directly translating the surgeons’ wrist movements.”
For patients, robotic hysterectomies may reduce the risk of complications, infections and infusions; decrease post-operative pain; and allow them to return to work more quickly. Adjuvant chemotherapy or radiation, if needed, can often be started weeks sooner than after open surgery because so little morbidity is associated with the robotic method.
Seven gynecologic surgeons at SCCA are trained in robotic surgery and have ready access to a da Vinci systems so patients can be scheduled quickly. All of our robots are dual console: two experienced surgeons work together, just as they would in open surgery, with one performing the surgery and the other assisting.
“It used to be that we’d have to make a large incision in the abdomen to do a hysterectomy. With this new robotic technology, we can offer a minimally invasive approach to many more patients,” says Goff.
Targeting obesity-related mortality among survivors
The most insidious and dangerous health threat for women diagnosed with endometrial cancer may not be their malignancy. Many survivors are overweight or obese, so they face significant health risks even if their cancer is cured.
“Obesity is probably the major cause of endometrial cancer. Being more than 50 pounds overweight means more than a 10-fold increase in a woman’s risk for this disease. Excess body fat causes other hormones to be converted into estrogen, which in turn causes the endometrium to grow and proliferate. That can lead to cancer,” explains Goff.
Of greatest concern are survivors’ risks for developing (or already having) type 2 diabetes, hypertension, cardiovascular disease or sleep apnea. “Reducing these risks can be difficult, but it’s essential. Some of these
women are cured of their cancer and then die relatively quickly of another condition that was treatable or preventable. Their cancer diagnosis is an opportunity for us to intervene to reduce their weight,” Goff says.
“At SCCA, we take a multidisciplinary approach to helping women make the necessary lifestyle changes. We not only treat their cancer, we also address what caused their cancer in the first place—the same issue that threatens their health most after their cancer is gone,” Goff says.
SCCA oncologists talk with endometrial cancer patients about their weight-related risks. Nutritionists work with them on dietary changes, and physical therapists advise them on safe exercise. Counselors are available to provide psychological support and discuss topics such as managing stress to reduce stress-related overeating.
“It’s important for patients’ primary care and other healthcare providers to be involved as well. This needs to be a coordinated effort,” says Goff.
By Leah Grant, Medical Writer
Colorectal cancer is one of the more common cancers in the United States, affecting approximately 140,000 people each year. More than 50,000 people are expected to die from colorectal cancer in 2012. However, there is good news; the death rate has been decreasing for more than 20 years, and one of the main reasons for this decline is screening. Through screening, adenomas, the type of polyp most likely to become a cancer, can be discovered and removed before they become cancerous and colon cancer can be detected early, when it is highly curable.
According to William M. Grady, MD, gastroenterologist at UW Medicine and Seattle Cancer Care Alliance, “Other screening tests, such as PSA for prostate cancer and mammograms for breast cancer, help detect cancer early, but they don’t actually prevent the cancer. By detecting and removing colon polyps before they have a chance to become cancer, we can prevent colon cancer.”
Clinical study of noninvasive screening tests
Grady is the lead SCCA investigator on a clinical trial studying leading-edge, non-invasive tests for the early detection of colon adenomas and cancer.
The study, Validation of Colon Biomarkers for the Early Detection of Colorectal Adenocarcinoma GLNE010 (NCT01511653), funded by the National Cancer Institute Early Detection Research Network, is a multi-center, 6,000-subject study of molecular markers for early detection of colon cancer. The target population for this study is adults 50 to 80 years of age undergoing routine colonoscopy. Two stool-based biomarkers and one serum-based biomarker will be compared with the current colon cancer screening standards: colonoscopy and fecal immunohistochemistry test (FIT).
“The FIT can detect 60 to 75 percent of colorectal cancer, but it is not as good at detecting colorectal adenomas (about 55 percent sensitive). Colonoscopy is the best for detecting polyps and colorectal cancers and is about 90 to 95 percent sensitive for colorectal polyps and nearly 100 percent sensitive for cancer,” says Grady.
Prior to colonoscopy or preparing for colonoscopy, patients who are interested in participating will need a baseline visit where they will provide informed consent and a blood sample as well as their gastrointestinal and general medical history, along with concomitant medications. Stool kits will be described and sent home with the patients. Stool samples are sent to the University of Michigan using prepaid UPS mailing labels. The initial appointment and colonoscopy are done at UW Medical Center.
The goal of the study is to validate the use of various promising biomarkers to detect colorectal adenomas or early-stage colorectal cancer. These biomarkers are non-invasive, like the FIT, but appear to be substantially more sensitive and specific than FIT for detecting adenomas. Thus, with a high sense of confidence, they could reduce the need for colonoscopy to only those with a positive biomarker. Using these non-invasive tests to predict colorectal cancer risk may ultimately replace the need for widespread colonoscopy screening.
“If we can find a biomarker test that can detect a colorectal adenoma with accuracy better than the FIT and close to the accuracy of a colonoscopy, we can eliminate the cost and complication risk associated with colonoscopy for many people. But the most important thing, from my perspective, is that it would be so much more convenient and should increase compliance with colorectal cancer screening, which is roughly 40 to 60 percent at this time.
Rather than having to do all of the things associated with a colonoscopy—the preparation, sedation, and take time off from work—you could just take a sample at home, mail it to the lab, and you’re done!” says Grady.
By Leah Grant
Radioimmunotherapy (RIT) uses an antibody directly linked to radiation (Fig. 1) to bind an antigen specifically associated with a tumor.
The binding of the antibody to the antigen initiates the process of programmed cell death (apoptosis), plus the antibody-radionuclide conjugate delivers a dose of radiation to the cancer cells. However, the success of RIT as a cure for
hematologic cancers, like leukemia, is hindered by one main problem. As John M. Pagel, MD, PhD, associate professor of medical oncology at the University of Washington School of Medicine explains it, “The challenge with RIT is that the dose a patient can receive is limited because the radioactive antibody circulates in the body before it binds to the cancer cells, which exposes non-cancerous tissue and organs to unnecessary radiation.”
Because of this limitation, many people relapse. Studies have demonstrated a dose-response effect, whereby escalating doses reduce relapse rates concomitantly. Pretargeted RIT, or PRIT, is a new treatment method
designed to improve the therapeutic index (target-to-nontarget ratio) by optimizing delivery of the radionuclide to tumors while minimizing radiation to normal organs. This allows the tumor to receive higher doses of absorbed radiation before dose-limiting toxicities occur.
Pretargeting the tumor
To achieve this, the delivery of the antibody (targeting vehicle) is separated from the radiation (effector). First, the unlabeled antibody is injected and allowed to circulate until it binds to the tumor sites. Any unbound antibody is cleared out of system. There is no toxicity associated with the antibody, so it doesn’t cause the damage that RIT does to non-target organs, such as the lungs, liver, and kidneys. After the antibodies are pretargeted to the disease sites, the therapeutic radioisotope is given.
PRIT uses molecular engineering to specifically target the radionuclide to the antibodies. “We think of it like Velcro, with its two complementary sides. Only in this case, we take advantage of the ultrahigh affinity that biotin and streptavidin have for each other,” Pagel says. “The pretargeted antibody with its part of the Velcro, streptavidin, is on the tumor site. Then the radiation with its Velcro, biotin, rapidly finds the antibody.” (Fig. 2) Because the radiation-biotin is a very small molecule, any that doesn’t bind with the antibody is quickly excreted, minimizing exposure of normal cells to non-specific radiotoxicity.
A growing number of preclinical studies (Fig. 3-below) and early clinical studies demonstrate that PRIT is safe and feasible, and provides dramatic improvement in tumor-to-whole body ratio, allowing administration and localization of very large doses of radionuclide, which may result in better efficacy and lower toxicities in patients with hematologic and other malignancies.
Clinical study information
Pagel is the principal investigator on a 30-patient Phase I/II clinical study that is recruiting patients known as the Donor Peripheral Blood Stem Cell Transplant (SCT) and Pretargeted Radioimmunotherapy in Treating Patients with High-Risk Advanced Acute Myeloid Leukemia (AML), Acute Lymphoblastic Leukemia (ALL), or Myelodysplastic Syndrome (MDS) (NCT00988715). Pretargeted radioimmunotherapy is provided primarily on an outpatient basis, targeting CD45 antigens that are present on leukemic, as well as normal, blood cells. Approximately one week after PRIT, donor stem cells are used to rescue the patient’s bone marrow.
“We are escalating therapy and delivering as high a dose of treatment as possible to people who normally can’t tolerate it, with the hope that it will keep the disease from coming back,” says Pagel. “Ultimately, our goal is to cure people. It’s early in the study, but our targeting is outstanding and we’re going to be able to deliver significantly more radiation than we can deliver any other way. So far, we’ve had some very nice responses. We’ll see how well it works as the study progresses.”
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.
Read about important outcomes research at the Hutchinson Center that may benefit your patients.
Each issue of Clinical Trials Monthly highlights several of the more than 200 clinical trials that are currently recruiting patients at SCCA.
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.