In this issue we present:
- SCCA Bone Marrow Transplant Program Ranks Among the Best
- IRE—Direct-Current Liver Tumor Treatment
- Preliminary Studies Show New Smoking Cessation Program 50 to 300 Percent More Effective than Traditional Method
- New Screening Guidelines for Lung Cancer
- Melanoma Meets its Match with Tumor-Infiltrating Lymphocytes
- Challenging Bladder Cancer with a Team Approach
- Obliteride –Riding Miles and Raising Money to Accelerate Research
- Continuing Medical Education
The Fred Hutchinson Bone Marrow Transplant Program at Seattle Cancer Care Alliance (SCCA) is one of 13 centers whose patients achieved higher-than-expected survival rates. This is according to the most recent multi-year study by the Center for International Blood and Marrow Transplant Research (CIBMTR). The CIBMTR compared patients at 168 bone marrow transplant centers in the United States over a three-year period for its 2013 Transplant Center-Specific Survival Report. Even people who have not found a matched donor may receive treatment at SCCA using a cord blood transplant or a haploidentical transplant.
Comparing Apples to Apples
“Comparing transplant centers in the U.S. is an extremely challenging process,” explained Marco Mielcarek, MD, medical director of the transplant program. “There are so many variables that must be taken into account; each patient has a unique risk profile. These patient considerations include their type of underlying cancer and cancer stage, the patient’s underlying medical problems and age, the type of transplant they undergo, and the source of the stem cells for the transplant.”
The point of all this intensive analysis is to enable researchers to compare apples to apples—and help patients and their families in their decision-making process as they’re evaluating where to go for treatment. “When you adjust for all of these risk factors, our patients’ outcomes exceeded expectations over this three-year period,” Mielcarek said.
To arrive at its findings, CIBMTR independently examined patient survival rates from 19,945 transplants performed to treat blood cancers at U.S. centers in the National Marrow Donor Program (NMDP) network. The reporting period for the 2013 report covered January 1, 2009 to December 31, 2011. During this three-year period, SCCA performed 762 allogeneic transplants. The report, published annually, is required by federal law. It is designed to provide potential stem cell transplant recipients, their families, and the public with comparative survival rates among transplant centers.
Said Fred Appelbaum, MD, executive director of SCCA and executive vice president and deputy director of Fred Hutch, “I’m very happy to see that our transplant patients during this period again had a survival that was better than predicted, and thus we ‘outperformed’ in the language of the CIBMTR. The study’s findings reflect the extraordinary and long-standing dedication by the staff of the Hutch and SCCA to improve the outcomes of our patients by continually refining transplantation to be a safer and more effective treatment.”
For people diagnosed with primary hepatocellular carcinoma, the world’s fourth most common cancer, SCCA and UW Medicine’s Liver Tumor Clinic offers irreversible electroporation (IRE), an emerging minimally invasive procedure.
First used clinically in 2010, this technique uses direct electrical current to cause cell death. It is a new avenue for patients whose tumors are close to vital structures and not candidates for more common treatments like radiofrequency ablation (RFA) and cryotherapy.
“IRE represents a relatively small percentage of the treatments that we perform, but it shows some of the best promise of any therapy in the last three to four years for liver and other tumors,” said Siddharth Padia, MD, an interventional radiologist at SCCA.
A technically demanding procedure, patients are under general anesthesia and a paralytic agent for two to six hours during which Padia, with ultrasound and CT guidance, inserts multiple probes into the liver. Their tips must be perfectly parallel around the tumor to generate about 3,000 volts of sub-thermal energy, which creates nano-sized pores in tumor cell membranes. The pores disrupt the membrane, resulting in cell death, and the body reabsorbs the dead tissues.
“There’s no heat,” Padia said. “You can potentially perform this treatment in tumors adjacent to the bile duct, gallbladder, and blood vessels.”
“IRE’s short-term results are very good, but prospective patients are advised that it lacks longitudinal efficacy data,” said Renuka Bhattacharya, MD, chief of clinical hepatology at UW Medical Center. In contrast, RFA has yielded more than a decade of data, so is used more frequently.
Additional options are TACE (transarterial chemoembolization) and TARE (transarterial radioembolization), the infusion of chemotherapy or tiny radioactive beads directly to the liver via the hepatic artery. These approaches are more often used in patients with several tumors.
Some liver tumors targeted for resection can be approached via the da Vinci robotic system. UW Medicine was first in the Pacific Northwest to use this technology in such cases. “The less-invasive approach is associated with lower morbidity and faster recuperation, so patients may undergo adjuvant therapy sooner,” said James Park, MD, UW Medicine surgical oncologist. “We are still pretty conservative in our selection process, reserving it for patients with the highest likelihood for success based on anatomy, tumor location and number, vasculature involved, and so on,” he said.
The mounting wave of hepatitis C and cirrhosis cases foreshadows increases in liver cancer. The years 2000-2010 saw a fourfold increase in new transplant candidates with hepatitis C among people born from 1941 to 1960, according to a study published by Liver Transplantation in December 2012.
“The incidence of hepatocellular carcinoma is expected to continue rising for the next 20 years,” Bhattacharya said. “We now evaluate about 250 new primary liver tumor patients per year at our center, and that number will continue to grow.”
Patients who have suspicious nodules or a mass, or whose cancer has been confirmed, should be referred to the Liver Tumor Clinic, which comprises practitioners across specialties, including UW Medicine transplant specialists. Patients can get opinions from multiple specialists in one day. A subset of this group meets weekly to discuss best options for each patient case–including whether a patient qualifies for a chemotherapy-based trial through SCCA.
“Typically patients’ liver function is so poor that surgical resection of a primary tumor is feasible for only a small portion of people,” Bhattacharya said. “At the other end of the spectrum, the medical oncologist offers chemotherapy for patients with very advanced tumors. Most patients fall between these two extremes.”
About 20 percent of liver tumor patients become transplant candidates. UW Medicine staffs the only large-volume liver transplant center in Washington. Since 1988, its surgeons have performed 1,704 liver transplants, almost 1,000 more than any other facility in the Pacific Northwest.
“We are moving forward with innovative treatments we can offer patients, and IRE is an example,” Padia said.
To refer a patient or learn more, contact the Liver Tumor Clinic by phone at (206) 598-0539 or by fax at (206) 598-1984; or contact the Liver Transplant Clinic by phone at (206) 598-4973 or by fax at (206) 598-4287. Read more about IRE.
Preliminary Studies Show New Smoking Cessation Program 50 to 300 Percent More Effective than Traditional Method
This month, Fred Hutchinson Cancer Research Center launched WebQuit.org, a website and research study to test two online smoking-cessation programs to learn which is most effective. Preliminary studies have shown that these programs are 50 to 300 percent more effective than traditional approaches to smoking cessation. Developed by Jonathan Bricker, PhD, WebQuit.org offers participants expert guidance and support to help them quit smoking, including a step-by-step guide, tools to help deal with urges to smoke, and help staying motivated while quitting.
Along with his team of researchers in Fred Hutch’s Public Health Sciences Division, Bricker has been developing the program since 2008, testing it with a phone-delivered program, group therapy sessions, and the WebQuit site, which is now currently being tested in a large-scale randomized trial due to the success of the completed pilot study. A smartphone app, SmartQuit, is now also in testing.
Lung cancer is the leading cause of cancer death for both men and women, and the majority of lung cancer cases—approximately 80 percent—are related to tobacco use. Each year, more Americans die of lung cancer than of breast, colorectal, ovarian, and prostate cancers combined. Despite these statistics and numerous public health campaigns aimed at curbing smoking, 20 percent of men and 15 percent of women smoked cigarettes in 2012, with about 78 percent of these people smoking daily, according to the American Cancer Society.
If you have a patient or patients over age 18 who smoke daily and would like to quit smoking in the next 30 days, encourage them to visit WebQuit.org to learn more and sign up for this innovative online quit-smoking program.
In 2013, the U.S. Preventive Services Task Force recommended annual lung cancer screening using low-dose computed tomography (CT) for adults aged 55 to 80 years who currently smoke or have a strong history of smoking (one pack a day for 30 years or two packs a day for 15 years, unless they quit more than 15 years prior). This recommendation first came into consideration after the National Cancer Institute (NCI) released the results of the National Lung Screening Trial (NLST) on August 4, 2011. This was a large-scale test of low-dose CT scans as a method for screening for lung cancer among patients at high risk for lung cancer.
The NLST was a randomized controlled trial that enrolled more than 53,000 current and former heavy smokers aged 55 to 74 and compared the effects on lung cancer mortality of two lung cancer screening procedures, low-dose helical CT and standard chest X-ray. This study found 20 percent fewer lung cancer deaths among trial participants screened with low-dose helical CT. The NLST was sponsored by NCI, a part of the National Institutes of Health, and conducted by the American College of Radiology Imaging Network (ACRIN) and the Lung Screening Study group.
The USPSTF recommends low-dose CT screening as a means to reduce the likelihood that an individual at high risk for lung cancer will die of lung cancer. SCCA offers low-dose CT scans for people who meet the screening criteria at the Lung Cancer Early Detection and Prevention Clinic. Call (206) 288-6734 for referrals and consultation scheduling.
Tumor-infiltrating lymphocyte (TIL) therapy is a promising form of immunotherapy being investigated at SCCA and three other centers across the country in patients with advanced melanoma. The overall response rate has been observed at 49 percent in early trials and the complete response rate has been observed at 12 percent. The majority of patients with complete response have not relapsed, with follow up as long as eight years, and many of the patients with a partial response have continued to respond for two years and beyond. This is significantly better than the outcomes for other U.S. Food & Drug Administration-approved melanoma treatments, including ipilimumab, and vemurafenib.
TIL are white blood cells called T cells that can be found infiltrating melanoma tumors and can potentially recognize and attack the cancer cells. But melanoma responds by suppressing TIL cells and placing them in a sleeping state. In this clinical trial, doctors are able to assist TIL in doing their job by removing TIL from the immunosuppressive environment that the melanoma has established in the patient’s body, reactivating them in the laboratory, growing them into the billions, and then reinfusing them back into the patient. The idea is that the high number of activated TIL cells will be able to attack the melanoma more effectively.
“This is an aggressive therapy that is only available to fit patients, but it is one of the most promising therapies available for melanoma,” said Sylvia Lee, MD, medical oncologist at SCCA and principal investigator for the TIL trial here. It takes the lab at Fred Hutchinson Cancer Research Center five to seven weeks to generate TIL cells from the melanoma tissue. Then they are ready for infusion back into the patient or cryopreservation for future use, if the patient is not ready for treatment.
Prior to TIL reinfusion, patients receive one week of lymphodepleting chemotherapy. After the TIL infusion, patients receive high-dose IL-2, which “feeds” the freshly infused TIL cells so the cells survive longer and attack cancer cells more effectively.
“It’s complicated,” says Dr. Lee. “And not just the TIL generation itself which is labor-intensive, but also lining everything up, finding patients who need treatment, but are healthy enough to participate in the clinical trial, making sure we have insurance approval for their trial participation, planning the timing of TIL infusion in the context of the patient’s clinical picture. However, it’s very exciting as well because we believe this therapy has the ability to change melanoma outcomes in a very meaningful way.”
More information about this clinical trial, Cellular Adoptive Immunotherapy Using Autologous Tumor-Infiltrating Lymphocytes Following Lymphodepletion with Cyclophosphamide and Fludarabine for Patients with Metastatic Melanoma is online at www.seattlecca.org/clinical-trials/melanoma-NCT01807182.cfm.
SCCA and UW Medicine opened the Bladder Cancer Multispecialty Clinic (BCMC) in January 2014 to provide comprehensive care to patients with muscle-invasive and metastatic bladder cancer.
Bladder cancer is the fourth most common cancer in men and 11th in women, with over 72,000 new cases diagnosed every year, accounting for over 15,000 deaths. For approximately 60 percent of bladder cancer patients who arrive at SCCA with muscle-invasive disease, care begins with a multidisciplinary team evaluation at this new clinic. This multispecialty approach may also be appropriate for patients who present with metastatic disease. The team includes a urologic oncologist, medical oncologist, radiation oncologist, pathologist, radiologist, and resident physician or fellow. All team members are UW Medicine physicians who specialize in genitourinary cancers.
The Multidisciplinary Appointment
The BCMC takes place twice a month for approximately four hours. The team develops individualized treatment plans specifically for each patient’s bladder cancer. Patients meet with each physician from the team individually to discuss the particulars of their treatment plan and get answers to any questions they may have. With SCCA’s multidisciplinary approach, patients are evaluated and have an opportunity to discuss all of the options and aspects of their proposed treatment plan on the same day with their individual treating physicians.
Treatment plans include surgery, neoadjuvant chemotherapy and surgery, or bladder-sparing chemotherapy and radiation. Care is coordinated across all specialties, so your patient doesn’t have to worry about scheduling each treatment session. The BCMC’s registered nurse coordinator also communicates the plan back to the referring physician.
Traditional treatment for localized and locally advanced bladder cancer has always included surgery. Today, surgery is not always necessary, and radiation therapy may be a good option for some patients. Treating bladder cancer with radiation therapy requires the experience and expertise of academic medical centers like SCCA and UW Medicine.
Metastatic bladder cancers are usually treated by a medical oncologist. However, among patients for whom surgery is the best option, neoadjuvant chemotherapy provides better disease control and survival rates. The coordinated, integrated approach of the BCMC makes these multimodal treatments as easy on the patient as possible. SCCA physicians lead and collaborate in many clinical trials for bladder cancer. This allows our patients to have access to leading-edge therapies not available anywhere else in the region.
Most bladder cancer patients begin their care at the BCMC, which is located within the SCCA Prostate Oncology Center at UW Medical Center. Depending on the treatment recommendations and the patient’s preference, patients can be treated at the SCCA outpatient clinic on south Lake Union or at UW Medical Center.
Referrals and Communication
The bladder cancer medical team is committed to providing exceptional care in collaboration with each patient’s primary and specialty care providers. Our physicians have developed a standard approach to communicating with referring physicians. As the team considers treatment recommendations, you will be informed and expected to continue providing care for your patient. To refer a patient to SCCA, contact our care coordinators at (206) 288-SCCA (7222) or www.seattlecca.org/referrals.
Last summer’s first annual Obliteride bicycling event raised $1.9 million for cancer research at Fred Hutch, which has already been put to work in prostate cancer, immunotherapy, and pediatric oncology research. Obliteride started in 2013. It’s a bicycling event dedicated to raising money for Fred Hutch, an SCCA founding member. In addition to being a great weekend of cycling and celebration, it’s also a community of people committed to ending cancer. Most importantly, 100 percent of every dollar raised goes to cancer research exclusively at Fred Hutch.
The Obliteride Weekend
The Obliteride weekend looks like this: Every rider and a guest are invited to the kickoff party on Friday at Seattle’s Gas Works Park. Last year, everyone enjoyed a fantastic dinner served by local, award-winning chef Tom Douglas and a concert by Michael Franti & Spearhead. On Saturday and Sunday, bicyclists can choose to ride 25, 50, 100, or 150 mile routes. Everyone celebrates together on Sunday afternoon with another great meal and outdoor concert at the Finish Line party at Seattle’s Magnuson Park. The 150-mile ride includes an overnight stay at University of Puget Sound in Tacoma, where riders will be treated to fantastic food and a concert by the Paperboys. The ride and festivities are all supported by a crew of more than 700 outstanding volunteers.
This year, Obliteride happens on August 8 to 10, 2014. We’re hoping you will consider riding with us, volunteering, and spreading the word to your patients and friends, so together we can put cancer in its place: behind us. Register at Obliteride.org and/or become one of our generous benefactors or sponsors at www.obliteride.org/sponsors.
GI Oncology 2014: Research to Practice
Friday, May 9, 2014
Location: Orin Smith Auditorium, UW Medicine South Lake Union Campus, Seattle, WA
Join us on Friday, May 9, 2014 for an exciting educational symposium designed to bring state-of-the-art information on current research and clinical management in the field of gastrointestinal (GI) cancers. A distinguished and internationally renowned faculty panel will share their expertise and foster discussion regarding the most recent breakthroughs and relevant research findings in GI cancers. The goal of the course is to provide information on clinical innovations and novel therapies to clinicians involved in the care of patients with GI cancers. Attendees will be exposed to new concepts, develop a broad understanding in management protocols, and receive updates on recent advances in therapy.
Registration information is available at www.seattlecca.org/cme.
Breakthroughs in Solid Tumor Oncology
Thursday-Friday, June 19-20, 2014
Location: Crowne Plaza Hotel, Seattle, WA
Hosted in partnership with the National Comprehensive Cancer Network (NCCN), this two-day educational symposium focuses on practice-changing discoveries in solid tumor malignancies, including advancements in personalized medicine, targeted therapies, and emerging clinical trials. Learn from the oncology experts from SCCA and UW Medicine.
Find registration information at www.seattlecca.org/cme.
5th Annual Comprehensive Oncology Review Course
Saturday-Tuesday, September 27-30, 2014
Location: W Hotel, Seattle, WA
This four-day intensive symposium will incorporate data supporting guideline-based recommendations and recent advances regarding the management of patients with malignant hematologic and solid tumor disorders. Attendees will have the opportunity to participate in case-based review sessions and discussions and will have access to a comprehensive syllabus and self-assessment materials.
For more information, visit www.uwcme.org. For more information about continuing medical education events, contact the SCCA Network Physician Education Office at firstname.lastname@example.org or (206) 288-1066.
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 Fred Hutch 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.