Cancer in a New Light
Fall 2005
Today successful cancer treatment combines a personalized treatment plan with additional support—from patient groups to complementary therapies—that helps the patient get through the difficult times.
Those who have been diagnosed with cancer often say that it changes everything. But cancer itself is changing. Today we know much more about what causes cancer to develop, grow and spread. This has led to the development of new classes of medication that show promising signs that future cancer treatment will be more effective, as well as far easier on patients.
Improved treatment and the use of screening tests to detect cancer as early as possible are producing impressive results. According to the American Cancer Society, the number of cancer deaths is declining. Yet, alongside the hopeful statistics are troubling ones: lung cancer deaths are increasing in women, there are disparities in cancer rates and survival between black and white Americans, and obesity-related cancers such as breast cancer and liver cancer are on the rise.
Today successful cancer treatment combines a personalized treatment plan with additional support—from patient groups to complementary therapies—that helps the patient get through the difficult times. At Emerson, the human side of care is a critical component. “We build a team around our patients with an emphasis on providing compassionate care and improving their quality of life,” says Jon DuBois, MD, chief of hematology-oncology.
Emerson’s comprehensive cancer program delivers the full spectrum of care: state-of-the-art diagnosis and treatment, a range of support programs and affiliations with Massachusetts General Hospital and Dana-Farber/Partners CancerCare so that patients don’t have to choose between receiving care in the community and downtown Boston. At the heart of Emerson’s program is the Bethke Cancer Center, which earlier this year received the top rating from the Commission on Cancer of the American College of Surgeons.
There is optimism among those who care for individuals with cancer. “We have excellent new treatments on the horizon, including molecular and genetic-based technologies,” says Dr. DuBois. “Today we talk much more about cancer survivorship and helping our patients live the rest of their lives.”
Prevention: What We Know
“There is no question we spend more time talking with our patients about prevention, including lifestyle changes and early detection through health screenings, than used to be the case.”
— Sandeep Jain, MD
Like most primary care physicians, when Sandeep Jain, MD, meets a new patient, he asks that they complete a health questionnaire. Childhood diseases, dietary habits and alcohol usage are of interest, but Dr. Jain also looks for the red flags that suggest the individual may be at risk for developing cancer.
One red flag is family history, especially when a family member has been diagnosed with cancer at a relatively early age. For example, the presence of colon cancer in a patient’s family illustrates the role preventive care plays today. It also helps explain why colon cancer rates are declining in men and women alike.
“Depending on the patient’s age, I may encourage them to have a colonoscopy, which can detect colon cancer at its earliest, ideally precancerous stage,” says Dr. Jain. “It might also make sense for the individual to have genetic counseling, which we offer at Emerson, to check for the syndrome that is associated with a high rate of colon cancer. This would give us a clear picture of the person’s risk.”
He would also address lifestyle factors, starting with diet. “We know that a high-fiber diet seems to protect people from developing colon cancer, as does reducing one’s intake of red meat,” Dr. Jain says. “In addition, research studies have suggested that baby aspirin and folic acid each help prevent colon cancer. So I would encourage the patient to take both of those on a daily basis.”
A generation ago, a physician would be unlikely to do much more than make a note in the patient’s chart that a family member had been diagnosed with colon cancer. That was before prevention became part of the cancer dialogue. “There is no question we spend more time talking with our patients about prevention, including lifestyle changes and early detection through health screenings, than used to be the case,” says Dr. Jain.
One lifestyle issue worthy of discussion is diet. According to Ena Sandler, MS, RD, outpatient dietitian, a low-fat diet that emphasizes plant-based foods—vegetables, fruits, whole grains, legumes and nuts—pays dividends in keeping people healthy. “It’s not just about what you shouldn’t eat,” she says. “What you should eat includes the omega-3 fats, which are found in fish and numerous foods of plant origin, including canola oil, flax and walnuts. These ‘good’ fats enhance the immune system and may play a role in preventing cancer.”
Individuals need to take a degree of responsibility, says Dr. Jain, by combining lifestyle changes with regular health screenings. “It doesn’t make sense to be passive,” he says. “People should take charge of their health and work with their physician to prevent serious illness, including cancer.”
Diagnosis: Technology is Progressing
“Technology keeps getting better and faster, and we are finding new ways to apply it.”
— David Rose, MD, chairman, Emerson radiology department
As medical imaging advances, so does its ability to diagnose cancer—not just earlier, but more precisely—and assist in planning more effective treatment. According to David Rose, MD, chairman of the radiology department, new technology is driving the process.
“The technology keeps getting better and faster, and we are finding new ways to apply it,” he says. Emerson’s 16-slice CT scanner will likely see its role expand with the completion of a major study of how to best screen individuals who are at high risk for lung cancer. Similarly, evidence is gathering to support the use of CT scanning to screen for colon cancer. “The research data on CT colonography is looking more promising,” says Dr. Rose.
MRI scanning is effective in specific areas of cancer diagnosis, says Mark Robbins, MD, a radiologist who specializes in that imaging technology. “It can detect the early involvement of cancer in bony structures such as the spine, as well as brain metastases,” he says. “MRI is complementary with ultrasound in evaluating gynecologic problems because it doesn’t expose women to radiation.”
Today women who are at high risk for breast cancer often receive an MRI scan, notes Dr. Rose, who is one of several radiologists specializing in breast imaging and diagnosis. “We have a lot to offer women, including digital mammography at the Breast Health Center in Concord and at the Westford Health Center, and breast biopsy guided by either ultrasound or MRI scanning,” he says. “At this point,
our main concern is that so many women do not come for an annual screening.”
Interventional radiology—the specialty area that involves minimally invasive diagnosis and treatment—plays a role in managing cancer and its complications, including pain. “When tumors appear in bone, we can treat them locally with ablation therapy—the use of heat or cold—which is effective against pain,” explains Adhip Mukerjee, MD, an interventional radiologist. “We can also obtain tissue samples for diagnosis using very thin needles and insert venous ports through which cancer patients receive chemotherapy and other medications.”
The next step for cancer diagnosis at Emerson is the arrival of positron-emission tomography (PET) scanning, which plays an increasingly important role in staging the disease and following its response to treatment. “PET, alone or fused with CT scanning, is revolutionizing how we evaluate cancer,” says Dr. Rose. “We expect to have this technology at Emerson in the coming months.”
The real future of cancer diagnosis lies in molecular imaging, says Dr. Rose. “This technology involves the injection of probes that perform DNA sequencing,” he says. “At that point, we believe we’ll be able to detect cancer at its very beginning.”
Cancer Genetics Program Opens
Most cancer occurs sporadically, but approximately 5-10 percent of cases are associated with family history—that is, a genetic syndrome that makes an individual susceptible to developing cancer. Earlier this year, Emerson Hospital introduced the Cancer Genetics Program, a service that assesses cancer risk in patients to determine whether or not they should undergo genetic testing.
The program is conducted in conjunction with Massachusetts General Hospital specialists and provides assessments
for the following cancers: breast/ovarian, gastrointestinal, renal cell and melanoma. Individuals who are concerned about a potential genetic risk for cancer should speak with their Emerson physician.
Feeling Good After Prostate Cancer
“Since having the surgery, my PSA has remained consistently low—less than one—and I don’t have symptoms related to recurrence.”
— Norman Harlow
Treatment for prostate cancer is not always clear-cut. Although Norman Harlow didn’t want to have surgery when he was diagnosed with prostate cancer three years ago, he is glad he did.
“I’ve read about ‘cure’ relative to prostate cancer,” says the retired commercial photographer and Littleton resident. “Since having the surgery, my PSA has remained consistently low—less than one—and I don’t have symptoms related to recurrence. I don’t know if that means I’m cured, but I feel pretty good.”
When his prostate-specific antigen (PSA) test—the standard screening test for prostate cancer—was found to be high, Mr. Harlow’s physician immediately referred him to Paul LaFontaine, MD, a urologist at Emerson Hospital, who performed a biopsy and diagnosed the cancer.
“My wife and I met with Dr. LaFontaine, who explained that the cancer was contained in the prostate, but it was somewhat advanced,” Mr. Harlow recalls. Unlike some cases of prostate cancer, his situation was not one where he could wait to see what happened. “Dr. LaFontaine explained my treatment options and potential side effects, and he was very meticulous. I felt confident about him.”
Although radiation seed implantation was an option, Mr. Harlow decided on a radical prostatectomy—surgery to remove the prostate—which Dr. LaFontaine performed at Emerson in April 2002. Thanks to the surgery, Mr. Harlow is in good health and, at age 74, works part-time for a local florist. “I’m on cholesterol-lowering drugs, but that’s about it,” he says.
Every six months, he checks in with Dr. LaFontaine for an examination and PSA test. Those visits will most likely drop down to once a year. “So far, so good,” says Mr. Harlow. “I made the right decision.”
Clinical Trials: Another Dimension of Care
Research continues to define improvements in cancer treatment. Patients being treated at Emerson have access to clinical trials—research studies that determine what works best for a specific type of cancer.
“Clinical trials are an important aspect of comprehensive cancer programs such as ours,” notes Susan Sajer, MD, a medical oncologist who serves as principal investigator for clinical trials at the Bethke Cancer Center. “We participate in clinical trials through the National Cancer Institute and Dana-Farber/Partners CancerCare, whose staff review all clinical trials before they are offered at Emerson.
“Participation in clinical trials is completely voluntary,” says Dr. Sajer. “When we meet with a new patient, we routinely discuss standard treatment, as well as clinical trial options. Clinical trials are for patients who wish to explore a new treatment. In the process, they help determine that treatment’s effectiveness.”
The trial that studied Herceptin, a targeted therapeutic antibody, is a good example of how access to clinical trials benefits individuals today, as well as future patients. “The trial compared Herceptin plus chemotherapy to chemotherapy alone in certain women with early-stage breast cancer,” explains Dr. Sajer, noting that Herceptin was found to reduce recurrences by 52 percent. “Herceptin combined with chemotherapy is now standard treatment for women with early-stage, HER-2 positive breast cancer.”
Dr. Sajer says participation in such important trials keeps Emerson in the mainstream of national research. “Our goal is not only to treat breast cancer and other cancers, but to learn about and utilize the latest approaches to cancer prevention, detection and treatment. Clinical trials are our best hope for the future. We encourage all eligible patients to consider enrolling in a study.”
For more information on clinical trials at Emerson Hospital, please call 978-287-3460 or visit www.emersonhospital.org.
Treatment: What is Working
“Today cancer treatment is much more specific—to the particular tumor type and to the patient’s individual situation.”
—Humberto Rossi, MD, Medical Oncologist
Cancer patients used to wonder which was worse—the cancer itself or the treatment. But during the past 20 years, the mainstays of treatment have become increasingly
precise. Minimally invasive surgical techniques, targeted medications and radiation that can be shaped to an individual tumor are proving to be effective treatments that are easier on patients.
Chemotherapy: Medications Are Evolving
Still, people often bring misconceptions to cancer treatment, says Humberto Rossi, MD, medical oncologist. “Many patients come to the office remembering their mother’s or their neighbor’s cancer experience, and they assume theirs will be the same,” he says. “We often need to explain that we are dealing with a different disease at a different point in time. Today cancer treatment is much more specific—not only to the particular tumor type, but to the patient’s individual situation.”
Chemotherapy is being continually customized, and the way it is administered is being fine-tuned. “We are using some of the older chemotherapy drugs in better ways,” notes Dr. DuBois. “That is true with breast and lung cancer, where we are finding that, with certain agents, patients respond well and have fewer side effects on a lower dose given more frequently.”
Then there are the new medications, known as targeted therapies because they focus on a specific part of a tumor. “We are seeing exciting results, particularly with breast cancer and lymphoma,” says Dr. DuBois. “Some targeted therapies are effective on their own, while others enhance the effectiveness of an existing chemotherapy. Either way, these new medications are usually associated with far fewer side effects.”
Cancer treatment is also being customized through supportive care: a range of approaches that addresses the symptoms of cancer or cancer treatment, including nausea. “With the advent of modern medications that have become available in the past decade, many of our patients are pleasantly surprised to find that we can prevent their nausea,” says Dr. Rossi. “It’s also true that today many patients do not lose their hair as a result of chemotherapy.”
Supportive care may include injections that increase a patient’s red blood cells and thus prevent anemia and fatigue, sophisticated pain management techniques, psychological and emotional support through counseling and support groups and complementary therapies such as acupuncture, reiki and yoga. “We have a certified acupuncturist at Emerson,” notes Dr. Rossi. “Some of our patients have found acupuncture to be successful in controlling their pain and nausea.”
There is no question that medical oncologists have more tools to offer their patients. “Between improved chemotherapy, the new targeted therapies and supportive care techniques, we can alleviate many complications associated with cancer,” says Dr. DuBois.
Surgery Is Being Refined
Surgeons at Emerson and elsewhere are making cancer surgery more precise and less invasive, and they are able to offer sophisticated reconstructive procedures, including after breast surgery.
The rate of colon cancer is dropping thanks to early detection through colonoscopy. At Emerson many of those who require surgery can have it performed as a minimally invasive procedure. “Careful study of laparoscopic colon cancer surgery has shown that it is as safe as traditional surgery; it is not associated with a higher rate of recurrence,” says Michael Reinhorn, MD, who performs the surgery at Emerson. “Our patients, of course, appreciate the shorter hospital stay and quicker return to a normal lifestyle.”
Tumors in the colon are almost always surgically removed. That is not true of prostate cancer—a complex disease that typically progresses slowly. “But when surgery is the chosen treatment, side effects such as incontinence and impotence occur less often than most men think,” says Paul LaFontaine, MD, urologist.
“We continue to refine the radical prostatectomy—removal of the prostate—in order to preserve the adjacent nerves,” Dr. LaFontaine explains. “As a result, we can preserve erectile function in the majority of younger men, and urinary incontinence occurs infrequently.”
Early detection of breast, colon and prostate cancer brings patients to treatment sooner. In that regard, lung cancer is a public health dilemma. It causes more deaths each year than those three cancers combined, yet there is no effective screening test. There is progress on the treatment side, including promising targeted therapies and minimally invasive surgery.
“Until about a decade ago, lung surgery required a big incision, called a thoracotomy, which cuts through muscles on the chest wall,” explains Loyde Romero, MD, chief of thoracic surgery. “Today we perform lateral thoracotomies, which require less cutting and result in a much easier recovery for patients.”
Video-assisted thoracic surgery (VATS) plays an important role, Dr. Romero notes. “For many lung surgery cases, VATS allows us to operate through two or three small
incisions using a scope linked to a video camera and sophisticated instrumentation. In addition, we now use a more precise staging system prior to lung surgery
that defines the extent of disease more completely.”
Radiation: Shaped and Focused
“We are able to deliver radiation that is shaped to the tumor and avoids healthy
tissue.”
— John McGrath, MD
Chief, Emerson Hospital-Massachusetts General Hospital Radiation Oncology Program
Radiation therapy is part of the treatment plan for approximately 50 percent of patients. Similar to the progress underway to improve chemotherapy and surgery, radiation oncology is being perfected in order to diminish side effects—mainly fatigue and skin irritation—and to make
it an easier experience for patients.
At Emerson’s Bethke Cancer Center, the technology includes 3D conformal radiation—a more precise way to administer radiation. “We design treatment using the patient’s CT scans,” explains John McGrath, MD, chief of radiation oncology. “By transferring them to our treatment planning center software, we are able to deliver radiation that is shaped to the tumor and avoids healthy tissue.”
According to Dr. McGrath, for some cancers the standard six to eight weeks of radiation is getting a second look. “We are offering certain patients with breast cancer access to an upcoming clinical trial that involves partial radiation therapy—one short week of treatment on a specific area of
the breast,” he explains. Another clinical trial
is studying a medication that appears to protect healthy tissue in patients with head and neck cancer.
Emerson’s patients benefit from the fact that the radiation oncology department is a satellite of Massachusetts General Hospital. “Our patients always seem happy to know that they are being treated by MGH physicians right here in the community,” says Dr. McGrath. “That connection is helping us to provide cutting-edge treatment, more precisely and, when possible, for shorter periods of time.”
Life After Breast Cancer: Creating a New Normal
“Cancer changes you, but I’m back to being me, and I have a life again.”
— Elizabeth Hill
In 2001, Elizabeth Hill entered a state of limbo. She was 32 at the time and preparing to celebrate her son’s first birthday when she learned that the suspicious lump she had found was invasive breast cancer. “When you receive news like that, everything stops,” says Ms. Hill, who has a history of breast cancer in her family. She was referred to Jon DuBois, MD and was immediately scheduled for surgery. A few weeks later, she began chemotherapy.
“I like to think of myself as being pretty tough, so my attitude was ‘bring it on,’” she recalls. It didn’t take long for side effects, including nausea, to appear, but with help from the oncology nursing staff she learned how to manage it. “The nurses at Emerson are the best people ever. They’re still on my speed-dial.”
Fortunately, Dr. DuBois suggested she consider participating
in a clinical trial being offered at Emerson. Herceptin, a new targeted therapy, was being studied to see if, when combined with standard chemotherapy, it reduces the recurrence of breast cancer in women whose tumors carry the HER-2 gene, which increases the risk that the cancer will spread. Ms. Hill didn’t hesitate.
“What I’ve learned about cancer is you need to find a physician you trust and you’re comfortable with; Dr. DuBois is awesome,” she says. “Then you do what they tell you to do, and if they offer you more—like taking Herceptin for a year—you say yes.” Ms. Hill said yes to a drug that has minimal side effects and, when taken with standard chemotherapy, has been shown to reduce the recurrence of breast cancer by 52 percent. Participating in the Herceptin trial has helped her regain her confidence.
“During my treatment I asked my father if I would ever be normal again, and he told me I’d find a new normal,” she recalls. “I’ve done that. Cancer changes you, but I’m back to being me, and I have a life again.”
Last fall Ms. Hill moved with her husband and son from Westford to Derry, New Hampshire, but she maintains a strong and grateful connection with Emerson, which includes seeing Dr. DuBois every few months. “You’re not treated like a number at Emerson,” she says. “The people there always have time for me. It’s my hospital.”
The Boston Connection Benefits Patients
Few community hospitals enjoy close relationships with world-class cancer specialists and research institutions. But Emerson Hospital does, and those connections
directly benefit patients and families.“Since Emerson is a formal affiliate of Dana-Farber/Partners CancerCare, our patients don’t need to choose between receiving
cancer care here or going downtown,” says Jon DuBois, MD. “We offer almost all the same therapies.”
The affiliation opens the door to Dana-Farber Cancer Institute clinical research trials, and it brings Dana-Farber specialists to Emerson. “Our Boston colleagues often attend our cancer panel meetings in which we discuss new patient cases,” Dr. DuBois explains.
Radiation oncology at Emerson is an actual department of Massachusetts General Hospital (MGH). “The treatment you receive at Emerson is often an exact duplicate of the treatment you would receive downtown,” says Robin Schoenthaler, MD, who along with John McGrath, MD, is a staff physician from the MGH department of radiation oncology. “We attend their department meetings, use the same computer system, and when necessary, receive instantaneous consultations from our MGH colleagues.”
Thanks to the Dana-Farber/Partners affiliation, Emerson physicians can easily collaborate with Boston specialists on their patients’ care plan. “That way, we don’t have to say good-bye to our patients,” says Dr. DuBois, who notes that area patients typically don’t want to say good-bye either. “They don’t want to give up the comfortable setting or the convenience of receiving their care in the community, close to family and friends. And they don’t want to give up the level of support they receive from us.”
