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Cancer center update

Our region is evaluating and providing some of the most advanced medical techniques and technology available.

Woodland Healthcare physicians gather at the weekly Tumor Board meeting to discuss difficult cancer cases.
Tony Novelozo

Putting breast cancer to the test

Every October for the past six years, NorthBay Cancer Center in Fairfield has held the Breast Cancer Update, a conference for doctors, patients and their family and friends. A topic of discussion at the 2007 conference was a genetic test called Oncotype DX, which was implemented at NorthBay in 2006.
    Oncotype DX is the subject of a clinical trial called TAILORx, which aids in the tailoring of breast cancer treatment based upon the risk of recurrence. “Genetic testing of the tumor cells allows oncologists to identify which patients are likely to benefit from chemotherapy,” says Dr. James Long, NorthBay Cancer Center Medical Director.
    The Oncotype DX test analyzes a tumor’s genetic makeup to determine a recurrence score. If the score is low, chemotherapy is considered unnecessary. If it is high, the benefit from chemotherapy is considered greater than average. But for women whose scores fall somewhere in between, the benefit of chemotherapy is not clear-cut. “The trial is designed to help the group with an intermediate risk score,” Long says. “Women in the middle group are randomly assigned to chemotherapy, or not.” TAILORx plans to enroll about 10,000 patients nationwide, which will put about 4,000 women in the middle risk study group.
     Ultimately, it is the patient’s decision to opt into the trial or not. “For women who are not comfortable enrolling and where the decision regarding chemotherapy is unclear, we do use the test outside of the clinical trial setting as well,” Long says. “But we feel strongly about the benefit of clinical trials for both the individual patient and for the benefit of cancer patients worldwide. We, as a community, will gain valuable information from the study. The upside from participation is the knowledge that one is helping fight cancer by adding to the knowledge base.”
    Further data indicates that the test may have broader application in the future. And, Long adds, “About one-third of [our] patients tested have been able to avoid chemotherapy because the genetic analysis showed their particular tumor had a low likelihood of spreading to other parts of the body.”

Fixed asset

In July 2008, Queen of the Valley Medical Center revved up its brand-new Siemens Biograph 40 PET/CT scanner, which allows a body’s function and anatomy to be studied concurrently during the same examination. Located in the Queen’s outpatient Napa Valley Imaging Center, it is the first fixed-site or nonmobile unit in Solano and Napa counties.
     In a PET (positron emission tomography) scan, a radioactive sugar is injected into the patient; cancer cells, which are highly metabolically active, will synthesize the tracer and then vividly appear on the scan imagery. “The more the affected cancer lesion accepts the radioactive tracer, the better the visual results,” Branham says.
    CT (computerized tomography, also known as CAT) captures images, or slices, of the body’s tissues, which are then reassembled to provide a cross-sectioned view of the body’s interior. The Queen’s new 40-slice scanner is an upgrade from the previous 16-slice system.
    “All the other PET/CT scanners have been, or are, mobile units that go to the site one or two days a week,” says Jill Branham, director of Imaging Services. “Patients needed to be scheduled around the unit’s availability. Our system is stationary, which allows the Queen to schedule patients around their schedule, not the other way around.” The Imaging Center is preparing to handle an increased patient load: More than 500 PET/CT patients, an increase of about 75% from the earlier part of the decade, and an increased load of CT-only patients are expected through 2008-09.
    “The new system helps physicians diagnose with more accuracy and speed, and to treat disease states earlier during the process,” Branham says. “PET/CT ultimately provides the physician with the window-seat view into the human body.”
 

On target

“Radiation therapy is no longer point-and-shoot, but involves relatively complex physics,” says Dr. Jeffrey Suplica of Radiological Associates of Sacramento (RAS). “One has to account for movement; organs may be in a different position from one day to the next.” Even seemingly trivial things such as the fullness of the stomach or bladder can create an extra challenge when accurately targeting a tumor.
    To that end, when RAS opened the Solano Radiation Oncology Center in Vacaville three years ago, its new state-of-the-art linear accelerator—a radiation treatment machine—was outfitted with image-guided radiation therapy (IGRT). IGRT is a system that aligns the patient in preparation for radiation treatment using CT scanning, ultrasound, digital X-ray imaging or another form of visualization.
    “We can capture the image of where that organ, tissue or tumor is right at the moment and calculate how to position that person and equipment,” Suplica explains. “It lets us be very precise in making sure the radiation is hitting the right spot every single time. With IGRT, I know that if I’m planning on being 1 millimeter away from the person’s eye, every day I’m exactly 1 millimeter away from the eye.”
    Currently, RAS treats about two-thirds of its patients with IGRT, which has gained more widespread use in the past five years. Before the advent of such technology, “we used to compensate by putting larger safety margins around the tissue,” Suplica says. “Now we can more precisely exclude the normal tissue from radiation. That can decrease long-term side effects such as bleeding, neurocognitive effects or lung and heart injury, as well as decrease short-term discomfort and side effects such as nausea or diarrhea. It’s very sophisticated, and does very nice treatments.”
 

Breathing room

One component of Sutter Solano Cancer Center’s (SSCC) roster of innovative services is respiratory gating, or active breath hold, utilized primarily for patients who are being treated for cancer in the left breast. “There’s difficulty in treating the left side, because [radiation] can catch a portion of the underlying heart and lung,” says Dr. Patricia Seid, a radiation oncologist with SSCC. The choice was often to either treat the entire breast and expose the heart to more radiation, or protect the heart but not eradicate as much of the disease. “With this technology,” Seid says, “we don’t have to compromise.”
    To prepare, an infrared camera is placed on the abdomen, which naturally rises and falls with the patient’s breath. “The tracking device tells us where in the respiratory cycle the patient is,” Seid says. “We want her to be at somewhere near maximum inspiration when we treat her, so that the chest wall and breast are farthest from the heart.” A steady breath cycle allows doctors to better track the tumor as it moves and targets the radiation beams, thus avoiding healthy tissue around it.
    In order to achieve the best results, a patient must hold her breath during treatment. (A therapist is present to coach the patient on when to inhale, exhale and how long to hold, anywhere from 10 to 40 seconds.) “Almost all women seemed to benefit when we evaluated their CT scan,” Seid says, estimating that 90 percent of those patients have successfully completed the treatment. “That is, their chest wall did in fact move away from the heart, allowing better sparing of the normal organ.”
    SSCC is currently evaluating how respiratory gating can be applied to other diseases, such as lung cancer. The technique requires specialized equipment and is not yet widely practiced. “Equipment holds back a lot of departments,” Seid says. “We’re pretty proud we’ve been able to do this.”
 

Man’s best friend in sickness and in health

When it comes to cancer research, the University of California, Davis, Cancer Center draws on a unique relationship with the Comparative Cancer Center at the university’s prestigious School of Veterinary Medicine. There, the Comparative Oncology Program tests cancer therapies on companion animals that will then hopefully prove effective and beneficial for humans.
    Established in March 2007 under the guidance of Dr. Xinbin Chen, a veterinarian oncologist, the center studies naturally occurring cancers common in companion animals—in other words, our pets—such as lymphoma, melanoma, osteosarcoma and prostate cancer.
    Dogs, cats and horses and sometimes even the occasional exotic animal are the perfect human case models, explains Chen. Whereas malignancies must be induced in the laboratory rodents commonly used in cancer research, cancers found in pets, as with humans, arise spontaneously and are often associated with age. Companion animals are also more closely genetically related to humans than are lab mice; even more relevantly, they share much of the same everyday environment—water, sleeping patterns, air, sometimes food—as their humans.
    The clinic’s dedicated team—about 20 members ranging from faculty to residents to nurses—treats anywhere from fewer than 10 to more than 20 patients a day. That may mean testing a cancer drug in animals that, if proven successful, will later be used in humans, or using a drug already proven effective for humans in the animals. The center’s more challenging goal is to develop and identify new drugs and to analyze how cancer works in companion animals.
    “We explore as much as we can,” says Chen. “It could take two to three years to really know what’s going on with a [known] drug. A discovery could take much longer than that. Our primary goal is to get better treatment for the animal. But in the meantime, if we can, we also want to apply [what we learn] to human cancers.”
 

Participation is power

With the understanding that cancer is a multidisciplinary disease, and “the idea that 10 to 15 minds work better than one,” Drs. Alborz Alali and Christine Zhang, oncologists at Woodland Healthcare, oversaw the advent of Woodland Healthcare’s Tumor Board in mid-2007.
    Weekly board meetings are attended by a range of medical specialists, from medical and radiation oncologists to gastroenterologists and pulmonologists.
“We start with the pathology of the patient, and what exactly the diagnosis is,” Alali says. “From each [doctor’s] aspect, we come up with a management strategy of how to best take care of the patient.” Meetings often begin with a quick rundown of all patient files, then move on to discuss three to five newer cases in more depth. “We want to make sure that patients have a treatment strategy in place—that nobody falls through the cracks.”
    Social workers and cancer support group managers also attend and recommend ways to emotionally support both the patient and the patient’s family. The board also encourages participation from patients.
    “The patients can come in, pose their questions to the surgeon, the radiation oncologist, the pathologist,” Alali says. “Instead of five different appointments,
they get their answers right away in one sitting. Empowering our patients with knowledge ... lets them be an active agent in decision-making.”
    As Woodland Healthcare expands—its new oncology building is expected to open in the winter of 2009—Alali foresees the board expanding with it. “Today, an acute disease can become a chronic one,” Alali says. “Cancer is not a death sentence anymore. This is a good time to take care of patients.”

 

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