Inactive (722)

Segment Number 3
Audio File allina_health/1433ah5c.mp3
Doctors Farhat, Elizabeth
Featured Speaker Elizabeth Farhat, MD - Dermatology
Guest Bio Dr. Farhat is a dermatologist and avid volunteer, having participated in medical missions in Botswana, Bolivia and Guatemala. She focuses her practice on early detection and prevention of skin cancer and improving overall wellness which starts with clear and healthy skin. Her health tip? "The key to preventing skin damage is to avoid mid-day sun, never use tanning booths and wear sunblock daily."
Transcription Melanie Cole (Host): From cellulite to wrinkles, from sunburn to freckles, the more you know about how to care for your skin, the better you’ll be at making the right choices to keep your skin healthy. My guest today is Dr. Elizabeth Farhat. She’s a dermatologist with Allina Health. Welcome to the show, Dr. Farhat. So let’s start talking about SPF and sunscreens because we all know how bad the sun is for our skin. But what is SPF, and how high should we be going with it?

Dr. Elizabeth Farhat (Guest): Absolutely. Sunscreen is so important to prevent sun damage and prevent skin cancer. When you're looking at sunscreens, I recommend looking for SPF 30 or higher. SPF actually stands for sun protection factor. What they do is they measure how long it takes for your skin to get damaged from the sun, and it's actually a factor that they multiply. So if normally you would burn in one minute, an SPF 30 would partner you for about 30 minutes. It also filters out about 97 percent of the damaging rays. So I always recommend higher SPFs are better because sunscreen does wear off. It’s not like you can put on an SPF of 100 and never put anything on again, because you do have to re-apply every couple of hours.

Melanie: The sunscreens that are labeled 50 and 70, do those make any difference?

Dr. Farhat: They do, but it's an incremental difference. So like I said, SPF 30 is about 97 percent of the rays. The 50 and 70 go up to 98, 99 percent. It's a difference, especially if you have sun-sensitive skin conditions or if you're really sensitive to the sun, but it's an incremental difference.

Melanie: Dr. Farhat, freckles are cute, especially on little kids. But when we’re out in the sun more, we tend to see more freckles. What are they, and are they really bad for us?

Dr. Farhat: Freckles do come from sun exposure, and what they are is basically pigment that your pigment cells are laying out into the skin. So when you go out into the sun, the sun stimulates those pigment cells or melanocytes to deposit pigment into the skin. So the more sun you have, the more freckles you can get, especially if you are light-skinned to start off with because you have less pigment to protect yourself from the sun. I don't think that they're dangerous, so they do not themselves turn into skin cancer, but they are a marker for sun exposure. So when I see people with lots of freckles, it just shows me that they’ve had a lot of sun over their lifetime.

Melanie: Now, what about skin regimes? What do you want us to do? What do you follow? And what's your best advice for skincare for ourselves?

Dr. Farhat: I think the most important thing is to keep your skin hydrated and cleansed. So typically, I’ll wash my face in the morning and use a facial moisturizer that has sunscreen in it. A lot of those facial moisturizers now have sunscreen built in, and the ones I like to use are those physical sunscreen blockers that have zinc oxide because those ones are less irritating to the skin, and you can put makeup right on top of the sunscreen or moisturizer. Then at bedtime, it is important to wash off any makeup or dirt that you’ve got on your face because those pores can get clogged overnight. And so, you can either just use a gentle face wash, or you can use wipes to wipe off any residue from the day.

Melanie: Now, as long as we’re talking about sunscreen and makeup with it, if we’re out in the sun and we get sunburned, are there some at-home treatments that we can use to ease the sunburn? We’ve heard about apple cider vinegar or aloe vera. Some people even keep the plants in their house.

Dr. Farhat: Absolutely. I do think aloe vera is a great one because it has a cooling effect on the skin, and that can help ease those symptoms of sunburn. As far as apple cider vinegar, I don't recommend that just because it can burn and sting, and it may even dry out the skin even further. One thing they’ve found is taking ibuprofen or other NSAIDs can decrease inflammation and help with the pain associated with sunburn, and so that is helpful to take, especially the first day that you're having that sunburn, just to decrease some of that inflammation and redness. And then you can always do cool compresses with a washcloth and cool water just to cool down the area, and make sure you stay really hydrated because your skin has to regenerate itself.

Melanie: Tell us about wrinkles. It’s everybody’s biggest thing with their skin as we age. We get wrinkles around our eyes and under our eyes and around our nose. How do we get wrinkles? Is smiling and those sorts of things, do they contribute to wrinkles? And is it something hereditary? Is there actually anything we can do about wrinkles?

Dr. Farhat: That’s probably one of the biggest questions I get is about wrinkles, and part of it is hereditary. Some people, their skin is just not as elastic as other people. But a lot of wrinkling does come from the sun. So, sunscreen is going to be the best way to prevent wrinkles from coming. As far as smiling, facial movements, you can get some dynamic lines from that, but a lot of people don't, so I would say I don't think it's something you should try to stop smiling or stop using your face for. But if you do get those wrinkles around the eyes from smiling, around the forehead from making facial expressions, the best treatment would be Botox because that’s going to relax those muscles that are really tugging at the skin. As far as the smaller wrinkles go, I do recommend using products that contain retinol. Retinol is over-the-counter, and it's been proven to reduce the look of fine lines and wrinkles. It comes from vitamin A, and it helps the skin to renew itself after. So it takes that skin from the bottom layer, brings it up to the top layer, helps your skin rejuvenate itself faster. And you can also try a prescription Retin-A or tretinoin cream.

Melanie: People see all these products on the market that contain retinol. So do you have any favorite products? Because some are very expensive, and some are not so expensive. Is the more you pay the better the product?

Dr. Farhat: I actually think what you want to look for is that key ingredient, so I don't know that you need to spend hundreds of dollars for the same product as long as it has that key ingredient. The main difference is just how it feels when it goes on your skin, so that’s called the vehicle. And I would say if you are happy with the less expensive option, I think that would be fine.

Melanie: So now on we move to cellulite. People have this on their thighs. They see it on the backs of their arms and on their abdomen. Is there absolutely anything besides weight loss that we can do for those little puckering in the skin?

Dr. Farhat: That’s another really common question I get. So cellulite is that dimpled appearance of the skin from those fat deposits that get pushed against that connective tissue. It’s really common on the hip areas, when you're walking, and it's more common in women than men because of the hormonal differences between men and women which causes more fat to be in women’s bodies, and then the distribution of the fat is over those areas that get cellulite. So the best treatment unfortunately is diet and exercise and just training those muscles so that you have less fat that’s overlying those areas to get pushed out into the skin. They’ve studied liposuction, unfortunately it doesn't work, and the topical creams really aren’t very effective because it is a deeper process. So I tell people, “Don't waste your money on all those creams and things like that.”

Melanie: So those creams and the things that we spread on that guarantee they're going to get rid of our cellulite, you as a dermatologist do not recommend us spending our money on those at all.

Dr. Farhat: Yeah. It might firm the skin on top of it temporarily, but it really won’t affect the cellulite underneath the skin.

Melanie: And Dr. Farhat, in just the last minute that we have or so, tell us your best advice for our best skincare to get that glowing skin that we all crave and why people should come to Allina Health for their skincare.

Dr. Farhat: I do think moisturization is really important. A lot of times, especially in the winter, people’s skin can get so dried out, and it really does cause your skin to look very dull and flaky. So using a really good moisturizer daily is so important, and then as I mentioned before, you can use one that has sunscreen in it to protect your skin from the sun. Most of the spots that people complain about, as far as aging, do come from the sun. So all the brown spots and all those things that pop up on your skin later in life are from the sun, so if you can protect yourself and prevent those spots from coming, that’s really the best thing. Then once you have had a lot of sun damage, I do recommend seeing a dermatologist once a year for a skin check because they can check and make sure there aren’t any pre-skin cancer spots or skin cancers. So I do recommend coming into Allina to see a dermatologist.

Melanie: Thank you so much. You’re listening to the Wellcast by Allina Health, and for more information, you can go to allinahealth.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole, MS

Prostate Cancer: World Leaders in Prostate Cancer Surgery

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Segment Number 4
Audio File city_hope/1432ch4d.mp3
Doctors Wilson, Timothy
Featured Speaker Timothy Wilson, M.D.
Guest Bio Timothy Wilson, M.D., is a nationally recognized leader in urologic oncology with expertise in prostate cancer, bladder cancer, testis cancer, kidney cancer, and urinary reconstruction. He is highly experienced with minimally invasive, laparoscopic and robotic-assisted urologic oncology, and is a renowned expert in robotic-assisted laparoscopic prostatectomy being one of the top six surgeons worldwide in terms of volume performing this type of surgery. His research interests focus on the early diagnosis and prevention of prostate cancer patients, identification of high-risk prostate cancer patients, and quality-of life-issues involving prostate and bladder cancer treatment. Working with other doctors and scientists, he participated in translational research that was awarded a National Institutes of Health R01 research grant. This research is directed at discovering improved techniques for diagnosing prostate cancer.
Transcription Melanie Cole (Host): City of Hope is actively developing tomorrow’s treatment protocols today for prostate cancer. As a patient of City of Hope, you have a highly-experienced and dedicated team to treat you and help you cope with cancer. My guest today is Dr. Timothy Wilson. He’s a professor and Chief of the Division of Urology and Urologic Oncology and the Director of the Prostrate Cancer Program at City of Hope. Welcome to this show, Dr. Wilson. Tell us about your approach to treatment for prostate and neurologic cancer care at City of Hope.

Dr. Timothy Wilson (Guest): Well, thank you, and thank you for inviting me to speak today. I think the most important thing to note about our treatment at City of Hope in evaluating patients is that no treatment fits all men. In other words, we like to think of each patient as an individual and we like to tailor the treatment plan based on the characteristics of that patient’s cancer.

Melanie: So tell us a little bit about prostate cancer, because we know, Dr. Wilson, that we women are who send our men into the doctor in the first place, whether they have symptoms or not. We force them in there. So tell us a little bit about some symptoms that men might notice themselves that would send them to see you.

Dr. Wilson: Okay. Well, that’s an important question because most men, in fact, that have prostate cancer don’t have any symptoms. Prostate cancer is the most common cancer in men in the United States and is the second leading cause of cancer death in men. So it is, it’s an important cancer, because it impacts so many men’s lives and their families. But as I said, most men don’t have any symptoms, although some symptoms could include problems with the urination, such as slow stream, getting up at night; so difficulty emptying one’s bladder. One unusual symptom that happens occasionally is also having blood in the semen. So, urinary symptoms are not uncommon when men are, you know, for a variety of reasons that can be an early sign of prostate cancer. But when men have later stages of prostate cancer, if there is spread of prostate cancer, then pain, bone pain can be a presenting symptom.

Melanie: What’s involved in screening, Dr. Wilson? Is PSA still the standard and the gold standard? Are there new genetic markers? Tell us about screening for prostate cancer.

Dr. Wilson: Okay. So, screening for prostate cancer really began to become widespread in the early 1990s when PSA first became clinically available. So PSA, which stands for Prostate Specific Antigen, is a protein effectively only made by prostate tissue. It turns out it is the best screening test we have for any one cancer. So it’s very accurate in that regard, but it’s not necessarily very specific. In other words, an elevated PSA -- this is part of the probable PSA -- an elevated PSA can be a sign of prostate cancer, but also be a sign of an enlarged prostate, or can be a sign of an enflamed prostate. Screening for prostate cancer, as I said, began in early 1990s and at that time, and since that time I should say, we’ve seen a decline in the death rate from prostate cancer of about 30 percent. But controversy has come up with prostate cancer screening because of PSA inaccuracies. In other words, as I alluded to earlier, an elevated PSA may not represent prostate cancer, but could be a sign of an enlarged prostate only, and not cancer, but also an inflamed prostate. So it’s up to the urologist to distinguish what the meaning of an elevated PSA is. So we still think PSA is an important test. We still use it. I still advocate it. There’s controversy because it’s that we may be over-diagnosing prostate cancer in men that may not need treatment. But the important thing, I think, is for men to work, and for doctors to work with a foundation of knowledge. In other words, we’d much rather know if someone has prostate cancer and the characteristics of it, and that can tell us, based on that and other factors about that individual’s health history, whether they need treatment, and if they do, what kind of treatment is best for them.

Melanie: Then, how really is it diagnosed and then you stage it; and then go on and tell us a little bit about some of the latest and hottest treatments that you’re doing out there for prostate cancer.

Dr. Wilson: Sure. So today, when men see their primary care physician, it’s still our recommendation that men be screened for prostate cancer on an annual basis and that screening typically uses the PSA blood test, as well as a physical examination of the prostate by the physician. If either one of is abnormal, again, it doesn’t mean that someone has prostate cancer but it means that they need further testing. Today, if men have either one of those two findings — an elevated PSA or an abnormal exam, such as a nodule that’s palpated on the prostate by the doctor -- then we recommend a prostate biopsy. And today, one of the significant advancements has been that MRI of the prostate is commonly used to evaluate the prostate in order to help direct the biopsies. And what we do today is fuse digitally the two technologies – MRI and Ultrasound – to help guide where the needle biopsies should go. So the standard of care today has become using ultrasound and MRI together to help the biopsy. It’s only with a biopsy or a small piece of tissue that’s collected from a needle biopsy of the prostate that pathologists can then look under the microscope at that tissue, and determine whether or not prostate cancer is there. And once we determine the prostate cancer is there, important factors are things like: how many of the needle biopsies that were done are positive for cancer, how much of those needle biopsies are actually involved in terms of kind of the percentage of the core of tissue. And also, what’s most important is the aggressiveness of the cancer; something that’s referred to as the Gleason Score. So, based on those factors, we then go on to stage the cancer; in other words, we try to find out whether or not it’s confined to the prostate or not. And those tests include things like bone scans, perhaps a CT scan, the MRI, not only of the prostate but of the abdomen and pelvis sometimes are done. Those are the primary things. Sometimes, PET Scans will be used, but they’re not so successful yet in prostate cancer. But again, staging really means, and is defined, is defining the extent of the cancer, whether or not it’s spread or not. And we use -- the PSA as an important predictor. How the prostate feels to physical exam is an important predictor, as well as the Gleason score. And then, these other sorts of radiographic or imaging scans that I have mentioned earlier.

Melanie: We don’t have a lot of time left, but tell us a little bit about Tomotherapy and that your team of experts was the first in the Western United States to offer this treatment.

Dr. Wilson: Correct. So, Helical Tomotherapy is a kind of radiation energy that’s used to focus a beam of radiation energy onto the prostate to pinpoint it. Day by day, combined with a small imaging scans, we know exactly where the prostate’s sitting and it’s roughly an eight-week course of treatment that can be accurately delivered over that period of time, typically with minimal side effects. It is true that City of Hope has become best known for our work with minimally invasive treatments, such as robotic prostatectomy. So we’ve become experts and have probably performed more robotic prostatectomies than any other institution, certainly in California and probably this side of the Mississippi. We have some innovative things going on, such as actually visualizing prostate cancer cells during the surgery to help make sure that we can get all the cancer out, but also help define whether or not additional tissues such as lymph nodes need to be removed, or whether or not we can safely spare very important structures around the prostate, such as these nerve bundles that are important for bladder and sexual function.

Melanie: Dr. Wilson, please tell why patients should come to City of Hope for their prostate and urologic cancer care.

Dr. Wilson: I think the important thing about City of Hope is that we approach each patient as an individual and we try to tailor the treatment plan for each patient. In other words, we don’t think that any one treatment fits all men necessarily. And we have a team of experts that work together for each patient to help develop that plan. This would include the urologist, such as myself, the medical oncologist and the radiation oncologist. So they get the team approach and the individual approach to that care. It really sets us apart from other institutions, not only inside of California, but around the world.

Melanie: Thank you so much, Dr. Timothy Wilson. You’re listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Brain Cancer: New Advances in Research, Treatment, Technology

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Segment Number 3
Audio File city_hope/1432ch4c.mp3
Doctors Badie, Behnam
Featured Speaker Behnam Badie, M.D.
Guest Bio Behnam Badie, M.D., an expert in the field of surgical neuro-oncology. He is currently working to transform brain tumor treatment through research collaborations using nanoparticles, engineered T cells, engineered stem cells and other novel treatments. This research is currently funded by the National Cancer Institute and other organizations.
Transcription Melanie Cole (Host): City of Hope researchers are conducting exciting clinical trials of innovative therapies to find out more effective treatments for patients with brain tumors. My guest today is Dr. Benum Badie. He is the vice chair in the Department of Surgery, the chief of Neurosurgery, and the director of the Brain Tumor Program at City of Hope. Welcome to the show, Dr. Badie. City of Hope is known for its collaboration between research scientists and physicians. Tell us about how that collaboration works in your case.

Dr. Benum Badie (Guest): Well, hello Malenie. Thank you for the opportunity to share some of the exciting research that's ongoing at City of Hope. I came to City of Hope because it provides a great environment for doctors and scientists to work together hand-in-hand to come up with new treatments for some of the tough problems. One of the toughest problems we have to deal with is treating brain tumors. Unfortunately, a lot of the brain tumors are malignant, and the survival is measured in only months and perhaps maybe a couple of years. The problem is that over the past few decades we've only made minor improvements in our treatments. So, it’s really important to think outside of the box and come up with novel treatments, something that would change the field. For example, we're on of the leaders in using cells to treat tumors. One that’s ongoing uses stem cells to deliver drugs into tumors. The stem cells have the ability to basically chase after very invasive tumors and they can actually release their cargo right next to the tumor cells. So this is a major breakthrough, and we've already done one clinical trial which ended last year. We showed that the cells are very effective as far as delivering their cargo, they're very safe to use, and we were one of the first centers to do this. So, we’re taking that research one step further, making more powerful stem cells to do the same thing but to release different types of chemicals in chemotherapies. So that's one of the very exciting research that's ongoing and in the next month or so, we will be opening some of the clinical trials for the stem cells again. Another research involves using our own immune cells. Our body responds to infections through white blood cells and this can target germs and bacteria. But unfortunately in the tumors, they are so smart that they actually knock out our immune system. So, we’ve come up with ways of changing that and we're monitoring the activity in the tumor, and were taking the patient's white cells, modifying them to specifically target those very invasive brain tumor cells. We’ve done two early stage clinical trials and we've shown that these are very safe to use. Our next third-generation T-cells are going to be much more powerful, and hopefully if we get the funding that we expect, the trial will open in the next couple months. So before the year is over, we’ll have two very exciting clinical trials for brain tumors that have not responded to other treatments. Those are very exciting research that’s going on. We are also working on nanoparticles to boost immune system. We're working on the various instruments and devices that could deliver volumes of cargos, like stem cells or T-cells into tumors. So, this is an example of the research that's going on here at City of Hope.

Melanie: And, Dr. Badie, who would be a candidate for these trials you've been discussing?

Dr. Badie: For now, we're looking for patients who have undergone standard treatment. Standard treatment after surgery is radiation therapy, and as I mentioned, unfortunately a lot of the tumors come back within a year. So, were looking for patients that are looking for clinical trials for malignant glioma. So, these are the glioblastomas that have come back after standard treatment. So any patient can be candidate. There are some requirements that we have to go through, but these patients can contact our research team, and we'll be more than happy to look at their qualifications.

Melanie: Dr. Badie, how do you think brain tumor treatment will progress in the next five or ten years? What are you looking at as the horizon to give some really exciting hope to patients with brain tumors?

Dr. Badie: As I mentioned, it’s a very difficult problem to solve, but in the research, both at our center and other centers, are coming out with new ways to target these. There's a lot of research on developing molecules that target specific pathways on how tumors are generated, but again one of the problems is delivering these molecules into the brain. So I think in the next five or ten years, we will come up with this better delivery of these targeted agents, so- called targeted agents or drugs. We will come up with new cells, some of the ones that I have mentioned, with immune cells that target part of the inflammatory and immune aspect of the tumor. There are research centers that are working on viruses that kill tumor cells. I think the only way we can make an impact is to come up with a sort of a multidisciplinary, multimodality approach. So, it won't be just surgery or radiation, chemo therapy; we have to come up with vaccines, drugs. There’s a lot of research that’s ongoing, and I think in the next five or ten years, they will probably merge together. Hopefully we could come up with a new treatment modality for these very devastating tumors.

Melanie: How is City of Hope's approach different than other brain tumor research centers, Dr. Badie?

Dr. Badie: Like some of the major centers, we have a multidisciplinary collaborative environment. We work very closely with each other, not only just the clinicians, but also scientists. We have meetings every week; we discuss patients. We have meetings every week; we discuss clinical trials and patient eligibility. We have scientific meetings every week, and I think that makes it very unique. I think what’s different—and that's something I noticed when I came here—is that people have a passion for what they do. I'm not saying that other people don't have passion, but some of the people who deal with cancer here were somehow affected by cancer in their families or some of them personally. So there's really a very unique passion of making a difference for not only brain tumor patients but other cancers. You don't notice that until you come here, and that's a unique environment, I think.

Melanie: And, Dr. Badie, in just the last minute or two, tell us a little bit about your team and why people should come to City of Hope for their brain tumor care.

Dr. Badie: When somebody comes here for second opinion or initially when they are diagnosed with a brain tumor, we have clinics attended by different clinicians. So basically, they come in and get a comprehensive basic opinion about what needs to be done. So, if they come to see a surgeon, that doesn't mean that they'll have surgery, but that will be discussed at these clinics and we come up with a sort of a best approach to deal with the tumor. So, it’s not always standard way; for every patient there's a different solution. There are the radiation oncologists, nuero-oncologists, surgeons, neurologists – everybody is involved in patient care. I think it’s the comprehensive approach that makes it very unique.

Melanie: Thank you so much, Dr. Benum Badie. You’re listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening and have a great day.
Hosts Melanie Cole MS

Breast Cancer: Compassionate, Individualized Care

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Segment Number 5
Audio File city_hope/1432ch4e.mp3
Doctors Mortimer, Joanne
Featured Speaker Joanne Mortimer, M.D.
Guest Bio Joanne Mortimer, M.D., is a breast and gynecological cancers expert. She has participated in clinical trials for over 30 years. Her research has focused on assessing the effects of systemic therapies on cancer and normal tissues. Many of these trials have utilized functional imaging and other biomarkers. She is studying the impact of toxicity on breast cancer disease outcome and quality of life. She and her colleagues reported a favorable outcome for women treated with tamoxifen who experience hot flashes.
Transcription Melanie Cole (Host): A breast cancer diagnosis is life-altering. The breast cancer program at the City of Hope offers a unique approach for women diagnosed with breast cancer and a team of doctors and expert researchers are turning innovative laboratory breakthroughs into promising new therapies that can impact patients today and focusing on the patient as a whole. My guest is Dr. Joanne Mortimer. She’s the Vice Chair of the Department of Medical Oncology and Therapeutics Research and the Director of the Women’s Cancer Programs at City of Hope. Welcome to the show, Dr. Mortimer. Tell us a little bit about your treatment approaches at City of Hope for women with breast cancer.

Dr. Joanne Mortimer (Guest): Our approach is very much patient’s family-centered care. And when patients are initially seen in our clinic as a new patient, they are first seen by a team of social workers who sit down with the patient and their partner, whether it’s a husband, a life partner, a family, relative; and they talk to them about what the expectation of this particular visit is. The advantage of screening patients ahead of time is that it gives you an idea of where the patients and their partners are, and we also teach the patient and their partner to get the most out of their initial visit. So, all patients are seen in this partner’s clinic and the screening system so that we know where the patients’ concerns are before they ever even see a physician. So, all patients are really evaluated by a surgical oncologist, a medical oncologist and a radiation oncologist, with or without a plastic surgeon depending upon the patient’s decision regarding surgery. So we have a very holistic and multidisciplinary approach to patients with breast cancer.

Melanie: Tell us a little bit about the screening. What’s involved? Women get this diagnosis. They’re very scared. It can be very devastating. Tell us what you do to screen them and how you decide upon the treatment approach.

Dr. Mortimer: So, most women start with the surgeon and the reason they start with the surgeon is because we need to get a biopsy to know that this is cancer and, in general, the initial approach to breast cancer is surgical, whether it’s a lumpectomy or a mastectomy or mastectomy and reconstruction. And so the surgeon is usually the first point, but the surgeon then refers the patient to a medical oncologist, if that’s appropriate or a plastic surgeon or radiation oncologist, depending upon what the need of the patient is and how our plan is to go ahead with treatment. Often, we give chemotherapy before surgery. So the medical oncologist sees the patient with the surgeon, and we discuss giving chemotherapy first to shrink the cancer down so the patient is more likely to be able to get breast preservation therapy. So, it’s a very individualized therapy and it really is based on the cancer that the patient has, as well as what the patient’s desires are in terms of whether they want to preserve their breast or not, and whether they want reconstruction right away or not.

Melanie: As a select number of cancer centres to provide intraoperative radio therapy, tell us about that, Dr. Mortimer.

Dr. Mortimer: So, It’s operative radiation therapy. It’s exactly that, it’s radiation that is given in the operating room and this means that you don’t need to come in for six and a half weeks just for radiation therapy. But there really are select individuals that are candidates for this, so this is not a treatment for young women. This is not a treatment for women with large cancers. Patients that we offer this to are older women who have small cancers that we’re fairly comfortable that can be removed at the time of surgery, so that the margin around the cancer is clean. And then the patient receives radiation in the operating room, and it’s done – it’s over and done with.

Melanie: Tell us a little bit about the cancer genetics program. We’re hearing more and more in the media today, Dr. Mortimer, about, you know, genetics and your risk for breast cancer. Tell us about the program at City of Hope.

Dr. Mortimer: So we have a very well-established clinical cancer genetics program. And this program has been ongoing for years, counselling women who have a family history of breast cancer. So, about one in 20 women with breast cancer have an inherited genetic predisposition for breast cancer. It doesn’t mean that – you know, your family history may be very strongly positive for cancer, but we may not yet know a gene for that particular cancer. So we refer our patients to the Clinical Cancer Genetics Department and they’re evaluated by a physician and a genetics counsellor and they’re talked to about the pros and cons of doing genetic testing; how likely they are that they may have one of these predispositions for cancer. And their blood is kept, so as new cancer genes are identified, it allows us to go back and retest these women in case they did have a strong family history, but they tested negative for the genes that we currently know. So it’s a very active research program at keeping track of all the patients that we see, so that when new genes are identified, we can screen for those genes. The value in knowing that you have a genetic predisposition relates to what surgery women decide to have. So, if someone has a predisposition for developing breast cancer, often women will opt to have bilateral mastectomy at the time of their initial cancer surgery and there is data that shows that by doing prophylactic surgery, that you do decrease the likelihood that someone is going to get another cancer. So there is a rationale for doing the genetic testing as far as helping, especially young women make a decision about are they going to have a lumpectomy and radiation; are they going to have a mastectomy, or in the most extreme, to undergo bilateral mastectomy.

Melanie: Tell us a little bit about breast preservation. Women have – you know, it’s a big part of us and a big part of our self-esteem and self-confidence. When women are going through breast cancer care, they do want to think about aftercare and want recovery will be like. Talk about how they’re going to feel afterwards.

Dr. Mortimer: Breast preservation, I think, has a lot of different meanings right now. You know, years ago when we talked about breast preservation, we would talk about women who opted to have a lumpectomy and radiation afterwards. So the alternative to taking off the lump and getting radiation to the whole breast was to do a mastectomy. Now, we have so many wonderful surgical techniques that allow women to have preservation of a breast after surgery. So, there are new surgical techniques that allow us to save skin and save the nipple even in some cases. So the surgeon can go in and take out all the breast tissue, but leave the nipple and the skin associated with it. And why that’s so important is that that allows the surgeon to put an implant in at the time of the surgery, the plastic surgeon immediately reconstructs patient, so that even though they’ve had a mastectomy, the breast contour and appearance is preserved, because of the type of surgery that’s performed. So classically, when we talk about breast preservation, we’re talking about doing a lumpectomy, taking the lump out and giving radiation to the breast afterwards. But I think, with the newest surgical techniques and the combined surgery with plastic surgery at the same time, doing nipples-sparing mastectomy really does preserve the appearance of the breast, as well.

Melanie: Dr. Mortimer, tell patients why they should come to City of Hope for their breast cancer care.

Dr. Mortimer: I think that the number one unique aspect of City of Hope is really the attention to the patient and their family. This is a devastating disease to go through, it affects the entire family and we address the entire family. Secondly, all our treatments really are state of the art, cutting-edge treatments, with a multi-disciplinary approach that includes an incredible group of compassionate physicians in genetics, in surgery, in our supportive care services in medical oncology, surgery radiation oncology. So I think it’s a very unique group of individuals who are absolute leaders in the field, know all the recent therapies and they are available here, and we do it with compassion.

Melanie: Thank you so much, Dr. Joanne Mortimer. You’re listening to City of Hope Radio. For more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Upper GI Cancers: Sophisticated Technologies for Life Saving Techniques

Additional Info

Segment Number 2
Audio File city_hope/1432ch4b.mp3
Doctors Kim, Joseph
Featured Speaker Joseph Kim, M.D.
Guest Bio Joseph Kim, M.D., is a surgical oncology expert in the surgical treatment of liver, pancreas, and stomach cancers.
Dr. Kim uses advanced laparoscopic and robotic techniques to perform his operations. This clinical expertise is the foundation for his translational research investigations, which incorporate his skills and knowledge as a surgical oncologist into the identification and development of novel targets and therapies for gastrointestinal cancers.
Transcription Melanie Cole (Host): City of Hope’s gastrointestinal oncology program takes an aggressive multidisciplinary approach to fighting cancers of the digestive system. My guest today is Dr. Joseph Kim. He’s the head of Upper GI Surgery and the director of Surgical Oncology Training Program at City of Hope. Welcome to the show, Dr. Kim. Tell us about the types of upper GI cancers.

Dr. Joseph Kim (Guest): Well, thank you for having me on the program. It's a pleasure to be here. When we talk about upper GI cancers, I think most commonly we’re referring to esophageal cancers and stomach cancers. So those are the two primary upper GI cancers that we’ll be speaking about.

Melanie: Are there certain races that are at higher risk for upper GI cancers?

Dr. Kim: Certainly. With regards to gastric cancer, there are select racial groups that are at very high risk for developing gastric cancer. It's very important for us here at City of Hope because we live in Southern California, and the racial groups that are at highest risk for developing gastric cancer are Asians and some groups of people from South America. So we see very high numbers of gastric cancers here because of our population in Southern California.

Melanie: Dr. Kim, what are some symptoms that someone might experience that would even send them to see you to check for esophageal or stomach cancers?

Dr. Kim: Well, unfortunately some of those symptoms are very non-specific. So people may have some difficulty swallowing. They may have some very non-specific abdominal complaints, a little bit of indigestion, some stomach discomfort. These of course can mimic normal conditions, problems that we may have after having normal meals, so it sometimes can be very difficult to diagnose these cancers.

Melanie: How are they diagnosed?

Dr. Kim: Well, typically, when people have persistent symptoms, they’ll go to their physician’s office, and the physician will order an upper endoscopy. So that’s the most common way that we will diagnose these cancers, with a camera that’s placed down into the esophagus or into the stomach.

Melanie: If somebody gets this diagnosis, it could be very, very scary. So tell us about some of the newer treatments at City of Hope used in treating these upper GI cancers.

Dr. Kim: Well, you're exactly correct that this diagnosis can be very scary. What we have to tell our patients is that cure is still a possibility with these cancers. What's special about the way that we treat these cancers, we use of course the standardized techniques to operate and remove these cancers, but also we employ some of the newest technologies, including laparoscopy and robotics, to take care of these cancers for our patients.

Melanie: When you're using surgery, you're removing the tumor, and then generally is there radiation, chemotherapy involved? And also, Dr. Kim, people hear about these types of cancers and they think they're not going to be able to eat anymore. They’re going to be maybe a little disfigured. Tell us about some of the recovery.

Dr. Kim: Yes, that’s a great question. So, the use of additional therapies may be recommended if patients have advanced disease. But we do see patients that have very early stage disease, and surgery alone is all that’s necessary to cure our patients. Our patients that do have advanced disease, we will have to employ or incorporate chemotherapy as well as radiation therapy. Having part of your stomach or esophagus removed will be life-changing for our patients, so we’re very careful in terms of counseling and advising our patients about the cultural, societal, family changes that they will have to undergo. For some of our folks, their daily meal is more than just eating, it’s a social event, and so they do have to readjust the way that they have to do things. Some of the basic outcomes for a gastrectomy or esophagectomy is that they do have to change the amount that they can eat at any one given time.

Melanie: What is some of the current research that’s underway at City of Hope for upper GI cancers?

Dr. Kim: Well, we’re doing some basic science, laboratory-based research, but we’re also incorporating research looking at new therapies for patients with advanced disease. So although esophageal cancer and gastric cancer can still be curative, patients who have advanced disease or metastatic disease, their outcomes still are far from where they should be compared to some of the other cancers where we’ve made significant improvements. So we have laboratory basic science studies, we have new therapy studies, and we have new imaging studies that are supported by the National Institute of Health to help us diagnose and treat gastric cancers better.

Melanie: We hear about colonoscopies; you get them every three to five years, testing for colon cancers. But endoscopies do not seem to be covered on the WellCare programs. They’re usually only given when indicated. When do you recommend people have an endoscopy?

Dr. Kim: Well, patients who have symptoms should certainly have endoscopies as appropriate. Again, most of the symptoms that we have are indigestion and can be easily treated with medical therapies, so we do have to be very careful about unnecessary endoscopy. However, that being said, Asian countries where gastric cancer remains the number one or number two cancers in those countries, they have incorporated nationwide screening programs where patients will undergo screening endoscopy at age 40. So, since we have many of those patients of those racial backgrounds living in Southern California, we’re trying to initiate a program so that those patients who are at highest risk can undergo such endoscopic procedures here.

Melanie: People have heard about Barrett’s esophagus and pre-cancerous lesions that might be spotted. Tell us about this. Is this a risk? Is eating spicy food a risk and damage your esophagus, and then if you damage your esophagus, are you then predisposing yourself to cancer?

Dr. Kim: Well, the Barrett’s esophagus is a pre-neoplastic lesion and it is certainly a concern, and people who have that diagnosis have to be followed closely as that can turn into an invasive cancer. Those patients probably aren’t developing Barrett’s esophagus because of the types of foods that they eat but more so from the exposure of the esophagus to the acids and bile from the stomach. People who are at the highest risk for developing gastric cancer, there are strong feelings that diet does play a role—not so much spicy foods but probably the salted, the fermented foods that are prevalent to any Asian and South American cultures. So I think those are some of the important risk factors. As well as the bacteria that can live in the stomach, the bacteria known as H. pylori, is a risk factor for gastric cancer.

Melanie: Dr. Kim, in just the last minute or two that we have left, tell listeners why a patient should go to City of Hope for treatment of their upper GI cancers.

Dr. Kim: Patients who may have an esophageal or gastric cancer should seek treatment at a hospital that takes care of those patients frequently. Because we are situated here in Southern California and we see a large number of patients with gastric and esophageal cancers, we have the experts not only for surgery but also for radiation therapy and medical oncology that can provide comprehensive care for patients with gastric cancer. Because these cancers can be relatively rare depending on the location where you live or the office that you go to, you certainly don't want to have a physician who has very little experience in treating those cancers. So our multidisciplinary care and our advance surgical techniques are really what set us apart from other places that may not take care of these cancers frequently.

Melanie: Thank you so much, Dr. Joseph Kin. You’re listening to City of Hope Radio. For more information, you can go to cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Transforming the Future of Cancer Surgery

Additional Info

Segment Number 1
Audio File city_hope/1432ch4a.mp3
Doctors Trisal, Vijay
Featured Speaker Vijay Trisal, M.D.
Guest Bio Vijay Trisal, M.D., is a surgical oncology expert in the field of skin and breast cancers. His research interests are focused on the patients with malignant melanoma, as well as the study of novel genes that may help in early detection and treatment of melanoma and the use of isolated limb infusion delivering high dose chemotherapy to treat locally recurrent disease. He is a member of the National Comprehensive Cancer Network committee that helps formulate guidelines for the treatment of melanoma both nationally and internationally.
Transcription Melanie Cole (Host): Studies show that cancer patients treated by specialists have better outcomes. City of Hope's Department of Surgery is at the forefront of surgical advances and specializes in the latest minimally invasive and laparoscopic procedures and is a world leader in robotic-assisted techniques. My guest today is Dr. Vijay Trisal. He's an associate clinical professor in the Division of Surgical Oncology and the medical director of Community Practices at City of Hope Medical Foundation. Welcome to the show, Dr. Trisal. Please tell us, what is surgical oncology?

Dr. Vijay Trisal (Guest): Thank you for having me, Melanie. Surgical oncology is an additional layer on top of basic general surgery. As you know, surgeons train in a residency program where they go through five, sometimes even seven years, of doing general surgery where they can do operations on every part of the body. But oncology, having become such a specialized field, not only understanding the surgical aspect but understanding the biology of the disease, how the cells behave, what new medications there are, adds another layer of training on top of the surgery. You have anywhere from two to four years of additional training with where there’s designated ACGME-approved programs in this country, which impart that training for two to four years’ time and mainly focusing on cancer surgery. When fellows come here and they ask about what this additional training does to them, it really concentrates, in my mind, 15 to 20 years of experience in this two to four years’ time, where what you would do and understand, let us say gastric cancer or breast cancer, by doing it yourself and learning, you would get that experience in two to four years’ time. That puts you at a level where you can really discern between the different complexities. So, like I was talking about gastric cancer last week, some gastric cancers are closer to breast cancers. Lung cancers are closer to melanoma, and no two lung cancers may be the same. There may be one lung cancer that is closer to melanoma as compared to another lung cancer. To understand that, this additional training, I think, is very critical.

Melanie: Dr. Trisal, why is it important for patients to see an oncology surgeon for cancer as opposed to a general surgeon?

Dr. Trisal: First of all, I don't think all cancers need to be seen by a surgical oncologist, although there clearly is more evidence, as you are aware of, that in complex cases, if you see a specialist, the outcomes are better. If you have a simple right-sided colon cancer, I don't think there is the huge difference in whether it is seen by a general surgeon or oncologist. But for the complex cases, whether it is esophageal cancer, whether it is pancreatic cancer, whether it is rectal cancer, whether it is a tumor called sarcoma or complex melanoma, the understanding of the disease and how you can tailor an approach to each patient, that additional training is A critical. There is data that has come out by looking at not just centers that have surgical oncologists but high-volume centers. So, pancreatic cancer surgery is complex surgery. If you're not doing a certain number every year, you do not have the understanding of which are the zebras in these, which are the ones where you may need to approach it differently first, where you may need to do chemotherapy first. So surgeons are trained to operate, and that is the first thing that has gotten, as one of my program directors used to say, that if you have a hammer, everything looks like a nail. And if you're a surgeon, you think of "Okay, can I cut this out or not cut this out?" But that approach in oncology is actually harmful sometimes because you may need to do chemotherapy first, you may need to shrink down the tumour and use radiation as one of your other hammers to see whether it comes off of critical structures where you have better chances of getting a negative margin. That understanding, I think, is better in surgical oncology, because of additional training, because of understanding the biology, because of what I think is more important is this interdisciplinary care. That means not only are you seeing the surgical oncologist but that surgical oncologist presents this case in an interdisciplinary setting with a medical oncologist, with the social worker, with the radiation oncologist, with the radiologist, and what you do get is you get 200 years of concentrated experience between the 10 of them that can guide you towards even an incremental better outcome.

Melanie: And what are some of the new cancer fighting medicines and technologies that are used by the specialists at City of Hope?

Dr. Trisal: Oh, we will have to have a half-day session for that. But for, let's say two or three diseases as a part of my passion and where my recent interests are, in melanoma for example, we have a huge deluge of new drugs that have really transformed how melanoma is treated. Ten years back when we looked at melanoma, we had one drug, one medication which was called Interferon, which used to basically be used in patients who had higher risks of recurrence. But what we have done is looked at the molecular targeting of these patients. We've seen that these cells evade the body's immune system. They say that the dumbest cancer cell is smarter than the smart oncologist, and these cancer cells are actually so smart that as soon as your body tries to fight it, it coats itself in a different envelop telling the body's immune system that "oh, it's its own friend, it's not a foe." What the newer drugs have done is they have done one of two things: One is, on one side, they have taken the brakes off of the immune system; that means where there was an order regulation of the immune system. So, if I get a bad cold and I have an allergy to something, that is when your immune system overreacts. But there's a balance in the system; you don't want the immune system to overreact, whereas when you have melanoma, you do want the immune system to overreact. So some of these drugs take the brakes off of the immune system and let our own cancer-fighting cells fight the cancer. Those are drugs like CTLA-4 blockers, which is called Ipilimumab. These are new drugs. The group of drugs that have come are called basically immune mediator drugs. On the other side, what we have also done is accelerated the immune process. So not only are you taking the brakes off of these cars so that it runs faster but you also put your foot on the accelerator. So, some of these drugs which are called PD1 or PD1 ligand blockers—those are called programmed deaths; PD stands for programmed death—what they do is, the cancer cells have this receptor, like an antenna on top that tells the body's immune system not to eat it, in simple words. But what these PD1 ligands do is they block that receptor and basically get this car to race faster so that the immune system can be up regulated. Similarly, let us talk about lung cancer or sarcomas. We are more and more looking at individual biomarkers, what are called targeted therapies or small molecule fighters. What they do is they look at uniqueness in these cancer cells. So, if one cancer cell has an antenna that is dissimilar than your body's own cancer cell, you can just target that. When we used to use chemotherapy, it is like a poison, rampant poison, it goes to the whole body and you think that all cells that are fast-dividing will die from this before the slow-dividing cells die. As you know, cancer cells are fast dividing so you feel that they will be killed first. But with this targeted therapy, they're pretty much honed and on to the cancer cells. So the antennas on top of the cancer cell will be the only one that picks up this molecule, and through a process that is a big cascade of reactions that happens, the cancer cell would die. That is where the focus on, whether that is colon cancer, whether that is breast cancer, whether that is melanoma or that is lung cancer or a prostate cancer, that is where the field is going.

Melanie: Dr. Trisal, in just the last minute or so, why is it so important for patients to come see a specialist at City of Hope?

Dr. Trisal: City of Hope is one of the most remarkable places in this country in the sense that you have a group of 230 physicians that just focus on oncology. There is camaraderie between the physicians that really percolates and translates into better patient care. And I think the focus is really on the patient. You get the group of people who formulate guidelines in this country, so we’re an NCI- designated cancer center, all the guidelines and system guidelines, there is a representative at City of Hope. That really gets the education not only to the group of people that are together but in this multidisciplinary setting you have different disciplines that coordinate with each other very well. You really have to see City of Hope to believe it, even right from the time you enter into the gate, from the person who takes your car to the person who greets you, the focus is really on the patient. When I came from Michigan, I really realized that it's not just another cancer center; it is elevated five notches above anything else I have seen.

Melanie: Thank you so much, Dr. Vijay Trisal. You're listening to City of Hope Radio. For more information, you can go to cityofhope.org. That's cityofhope.org. This is Melanie Cole. Thanks so much for listening. Have a great day.
Hosts Melanie Cole MS

Lung Cancer: New Screening and Advanced Treatment Options

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Segment Number 5
Audio File city_hope/1431ch1e.mp3
Doctors Raz, Dan J.
Featured Speaker Dan J. Raz, M.D.
Guest Bio Dan J. Raz, M.D., is a surgical oncology expert in esophageal and lung cancer surgery. Currently, he serves as Co-director of the Lung Cancer and Thoracic Oncology Program and Director of the Lung Cancer Screening Program at City of Hope. His research involves novel lung cancer therapies and biomarkers, as well as research on improving access to and quality of lung cancer screening.
Transcription Melanie Cole (Host): Having a lung cancer screening, chest CT, reduces the chance of dying from lung cancer by 20 percent in those with very high risk of developing lung cancer. My guest is Dr. Dan Raz. He’s the co-director of Lung Cancer and Thoracic Oncology Program and the Director of the Lung Cancer Screening Program at City of Hope. Welcome to the show, Dr. Raz. Why should people get screened for lung cancer and who should get screened?

Dr. Dan Raz (Guest): Thanks for having me. Lung cancer is the most common cause of cancer just by far in the United States and worldwide. It kills more people than any other cancer in white people, African Americans, Latinos, Asian Americans, so it’s important to everyone. The reason it’s the major cancer killer is that most of the time it’s found when the cancer has already spread throughout the body. When we are fortunate enough to catch it early so that we can cure lung cancer, we usually find it by accident. But now with lung cancer screening, we can find lung cancer early when it can be treated and when it can be cured. The people who should talk to their doctors about lung cancer screening are people who are current or former smokers. So there are several different guidelines but the most common guidelines are for people between the ages of 55 and 80 who've smoked at least 30 years of cigarettes.

Melanie: Wow. So, people checked with their doctors about lung cancer screening, what's involved in the process?

Dr. Raz: It's very easy. It's a painless scan that takes just a few seconds. There is no IVs that need to be inserted. You only need to take off your shirt or anything like that. You lay down in the scanner and you hold your breath and it’s a very quick scan. The amount of radiation that's used is very, very low. It's about the same amount of radiation that's used in a mammogram.

Melanie: And what are the results look like to you, Dr. Raz? What would you see that would signal the risk for lung cancer?

Dr. Raz: What we are looking for are nodules. Nodules are spots on the lung that are not normally there. Most of the time, when you scan people, many people have nodules that aren’t even cancerous but some of those do turn into cancer. We have very specific ways of figuring out which nodules are cancerous, which nodules aren't cancerous, without having to do invasive testing like biopsies. So, we've become very sophisticated at figuring out which people need additional testing, whereas other people may just need to get a repeat CT scan in several months or even at a year’s time. So, we have a very good system of looking at the scans and understanding who is at higher risk for lung cancer. We also find things on lung cancer screening other than lung cancer that are tobacco-related, such as coronary artery disease or emphysema that people may not even realize that they have.

Melanie: What are some of the biggest developments at City of Hope in treating lung cancer?

Dr. Raz: I think one of the major advances in addition to lung cancer screening has been the advent of minimally invasive and robotic surgery for lung cancer that's allowed us to treat people in a way that they can turn to their normal life, return to work very quickly. It’s allowed us to treat patients who are elderly without setting them back, without them losing their independence. We’ve also developed new techniques for radiation therapy that allow us to treat patients who normally wouldn't have been able to undergo any kind of treatment for lung cancer. Then for more advanced lung cancers, we have very advanced and sophisticated clinical trials using targeted treatments. They're based on the actual changes within the cancer itself.

Melanie: Dr. Raz, what sets City of Hope apart in treating lung cancer?

Dr. Raz: I really think there is nowhere else like City of Hope for lung cancer for a couple of reasons. First, every cancer patient here lives and breathes lung cancer. We only treat lung cancer patients. I am a surgeon who specializes in lung cancer. Our cancer doctors are lung cancer specialists. We are focused on not only providing cutting edge care but also on quality of life and really treating patients holistically. I think patients who get treated here not only benefit from the scientific advances but also feel a nurturing environment and really get the best, in terms of their quality of life.

Melanie: Speak about some of the lung cancer research program studies that you are doing there at City of Hope.

Dr. Raz: Well, we have a number of clinical trials looking at new treatments for lung cancers that are very promising. We also are investigating new treatments like a derivative of a Chinese herb for lung cancer treatment, and we have extensive research on quality of life in lung cancer patients, trying to figure out, how do we make treatment for lung cancer better in terms of not just extending life but improving quality of life along the way?

Melanie: Tell the listeners. You mentioned about why they should get screened, but speak about some lifestyle modifications, prevention, risk factors for lung cancers, so that you could affect them right now and maybe they don't have to come see you.

Dr. Raz: Sure. Well, anyone can get lung cancer. That's one thing that’s important to know. There is such a stigma with lung cancer with regards to smoking but even people who have never smoked cigarettes can get lung cancer, and we see patients like that unfortunately time and time again. But quitting smoking if you are currently smoking, not starting to smoke if you’re kind of just early in the habit, is the most important thing that you can do to prevent lung cancer. There’s a lot of interest in electronic cigarettes and what that means in terms of lung cancer risk and we just don't know right now. Electronic cigarettes unfortunately have many, many chemicals in the vapor, and so there are a lot of misperceptions about electronic cigarettes being just water or vapor when they're not. I don't think we'll be able to answer that question for many, many years, but in terms of being proactive about your health, quitting smoking if you currently smoke and getting a lung cancer screening, CT, are the most important things to do currently.

Melanie: And what might send somebody to see you? Just give a few symptoms, and then in the last minute tell people why they should come to City of Hope for their lung cancer care.

Dr. Raz: Symptoms of lung cancer are cough that doesn't go away for several weeks, coughing up blood, unexplained weight loss. Those are some of the more common symptoms of lung cancer. Unfortunately, as I mentioned before, most early stage of lung cancers that we can cure don't cause any symptoms at all, which is why screening is so important. I think the reason to come to City of Hope, again, first, for your lung cancer, is that we are all lung cancer experts here. We know the least and greatest. Our surgeons here, including myself, do robotic and minimally invasive surgery for lung cancer. We have cutting edge radiation oncology techniques for patients who aren’t eligible for surgery. In terms of oncology care, we have just a number of clinical trials and quality-of-life trials that allow patients to have access to drugs they otherwise wouldn't have access to. As I mentioned before, City of Hope is just such a special place, and that no other place that I've been to combines cutting-edge treatment with such a nurturing environment that focuses on the quality of life and the patient as a whole as City of Hope does.

Melanie: That's why it's so important to get screened for lung cancer at City of Hope because it can increase the chance of diagnosing lung cancer at an early stage when it is more likely to be cured. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That's cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Hosts Melanie Cole MS

Clinical Trials: Life Saving Research. Might You Be a Candidate?

Additional Info

Segment Number 4
Audio File city_hope/1431ch1d.mp3
Doctors Zaia, John
Featured Speaker John Zaia, M.D.
Guest Bio John Zaia, M.D., specializes in Pediatric Infectious Disease, with a particular interest in infections of immunocompromised patients, especially transplant recipients and HIV/AIDS patients. His clinical research involves the development of stem cell approaches for control of HIV/AIDS using gene therapy, and his team was the first to apply such approaches to AIDS lymphoma. His laboratory studies innate immunity to cytomegalovirus (CMV), and he was the principal investigator on the first evaluation in humans of a peptide based CMV vaccine developed at City of Hope.
Transcription Melanie Cole (Host): The aggressive pursuit to discover better ways to help patients now—not years from now—places City of Hope among the leaders worldwide in the administration of clinical trials. My guest today is Dr. John Zaia. He is professor and chair in the Department of Neurology and director of the General Clinical Research Center at City of Hope. Welcome to the show, Dr. Zaia. Tell us, what are clinical trials?

Dr. John Zaia (Guest): Clinical trials are a test of whether a new treatment is safe and whether it works. Basically two kinds: There are those that we call therapeutic, that is, the intent of these trials is to see whether the treatment is better, because the outcome is to cure better than the standard therapy. The other is called nontherapeutic, in which you’re just trying to find out a better way to manage a patient, a better diet for the patient, whether exercise programs are better for a patient, whether a diagnostic test is better, that is, you can actually determine whether a person is at a low-risk group or a high-risk group if they come in with a new diagnosis. So, in summary, you have a therapeutic trial and a nontherapeutic trial.

Melanie: When we look at the different types of clinical trials, prevention, or screening and detection, are these all parts of it from prevention of a particular disease all the way through quality of life and in the treatment room?

Dr. Zaia: Yes, they involve the full spectrum. How do you assess a patient on the first day that you see him, that is, how do you determine? Can you categorize him into a person that is going to do really well and therefore does not need aggressive treatment or a patient that is going to need more aggressive treatment? All the way through the process to the end, and then you assess: What that this done to their quality of life?

Melanie: So what would be the benefits to being involved in a clinical trial? What patients would be interested in getting involved?

Dr. Zaia: That's a difficult question, and the reason I say that is that certain of our trials are the first time a new treatment has ever been used in that patient; it’s usually for an illness for which existing treatment just doesn't usually work. When we do that, it's so experimental that it may be what we call a first-in-human trial. We have several first-in-human type of trials here, which means that we don't know what’s going to happen; we're really doing this to see if it's safe. We tell the person that we cannot expect a benefit.
Many of the other trials though are in Phase 2 and Phase 3, we call it. So, once you are out of that first phase, we call it a Phase 2 to see how good a new treatment is, and then Phase 3 is when how good it is compared to the existing alternative. When you get to that part of the trial—and I’m talking, of course, about the therapeutic trials—there is a good chance of benefit. We explain that at least they’ll be getting as good a benefit we think as the standard of care.

Melanie: Dr. Zaia, what does it take for a clinical trial to get the Phase 4, to where it starts to be looked at by the Food and Drug Administration and approved?

Dr. Zaia: Actually, Phase 4 is where it’s approved and then you actually use it in its approved agent. You continue to monitor people that are on that treatment. How do you get to an approved drug is what you are really saying. That is a multimillion-dollar question. I say that because it takes so long for the safety trials to be completed and for the trials to determine, what's the best dose of a new treatment? Then the large population studies is when you are actually comparing this to standard of care. It usually takes between 5 and 10 years to get a new agent. There are accelerated programs for certain illnesses, for which there's absolutely no treatment, no successful treatment. But except for the accelerated pathways to the FDA, it can take between five and ten years.

Melanie: What’s a protocol? How do people assure themselves if they are interested in getting involved in the clinical trial about the safety and efficacy of a clinical trial?

Dr. Zaia: Okay. The safety of a clinical trial is vested in what we call the protocol. The protocol is actually just the description of what will be done to the patient while they are on the trial. But it is minutely detailed. So we try to anticipate all kinds of problems even if there are side effects. With certain kinds of side effects, we say, “If that were to happen, then you decrease the dose by so much, and if the patient feels sick before the next treatment is given, you delay the treatment until the patient gets over whatever the problem is.” We make sure that their white count is the right low if the treatment is something that would reduce the level of their white blood cell count. Now, the safety of the trial is in the correctness of the protocol and in the ability to follow the protocol correctly. I say that only because when you go to the doctor normally, the doctor is looking after you, but when you’re on a clinical trial, the doctor is looking after the protocol, and he's doing that because that’s the best way to protect the safety of the patient. If he gets offline and starts treating off protocol, let’s say, in the midst of the trial, then there could be problems. There are certainly regulatory problems that the FDA will object to, which you are not doing like you say you'd do it and we approved it according to the exact way that you said that you’re going to do it. So, for safety, we use the so-called protocol, and it’s reviewed and reviewed and reviewed by multiple committees and is reviewed by the FDA, and once it’s finally set, then we begin the trial.

Melanie: You've explained that so well, Dr. Zaia. What are some of the innovative trials going on right now in City on Hope?

Dr. Zaia: Well, the biggest area, I think, for innovation in cancer is cellular type therapy. When I say “cellular,” I mean you take the patient's own natural cells: T-lymphocytes, which are the immune cells; or even stem cells, which are the parent cells for the blood and your immune system. We actually take those cells and we treat them in the laboratory in a certain way to make them more effective, for example, at recognizing a tumour. So, the T-cells are then taken from a patient, manipulated in the laboratory so that they can recognize the tumour, and then given back to you. That's one series of experimental trial and treatments that we have had going. We have stem cells therapy to try to determine if you can genetically make an immune system that's resistant to an infection. For example, AIDS virus-- so we are currently enrolling patients who have had or have AIDS, who’ve even had a lymphoma that's been successfully treated, and we now are taking their stem cells, genetically making them resistant to the AIDS virus and then infusing them back in to see whether or not they would then not only be cured of their lymphoma but also of their HIV infection. There are, of course, new anti-cancer agents. They’re becoming available, and there's more and more of those all the time. I think that what City of Hope offers is access to the latest available therapies. So, we get those from a number of sources: We make some of them here, from our own discovery, but many of them come from the outside, mostly from pharmaceutical industry. The pharmaceutical industry, of course, is very anxious to test these new agents, but we are also very anxious to get the latest agents as well. So about 25% of all of our trials come from the pharmaceutical industry and this gives us access then to agents that have great promise. That is a major reason, I would say, why you should come to City of Hope, if you have cancer, because you then have access to this kind of agents.

Melanie: And how does one get more information about joining a clinical trial at City of Hope?

Dr. Zaia: There are two ways, I would say. There’s the City of Hope website, which is cityofhope.org. When you go to that website, there are a number of things you can go to, but you can go to “how to find your doctor.” But there is also research at City of Hope and you can then look up “clinical trials online,” we call it. It has a Spanish and an English version. You can then put in the type of illness you have (lymphoma, breast cancer, lung cancer) and see what kind of clinical trials we have. Or you can just call the New Patient Office. The New Patient Services is at 1-800-826-4673. That’s 1-800-826-4673. At that office, they can direct you to the right place for your particular problem.

Melanie: Thank you so much, Dr. John Zaia. You're listening to City of Hope radio. For more information on clinical trials at City of Hope, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.

Pathology: Results Oriented at City of Hope

Additional Info

Segment Number 3
Audio File city_hope/1431ch1c.mp3
Doctors Weisenburger, Dennis
Featured Speaker Dennis Weisenburger, M.D.
Guest Bio An internationally recognized authority on hematologic malignancies, Dennis Weisenburger, M.D., is an outstanding physician-researcher, collaborator, and mentor. He has contributed significantly to the field of pathology and malignant hematology, and holds two patents for his work in lymphoma prognosis. In addition, he helped develop the Nebraska Lymphoma Study Group and served as chief pathologist for the collaborative clinical research network. He’s received international recognition related to his work on classification of Hodgkin and non-Hodgkin lymphoma.
Transcription Melanie Cole (Host): Led by pathologists renowned for diagnostic excellence, the Department of Pathology at City of Hope combines state-of-the-art laboratories equipped with the latest diagnostic techniques and advanced instrumentation with superior investigative skills to accurately and rapidly identify even the rarest and most complex diseases.

My guest is Dr. Dennis Weisenberger. He’s an internationally recognized authority on hematologic malignancies and the professor and chair in the Department of Pathology at City of Hope. Welcome to the show, Dr. Weisenberger. So it’s critical that newly diagnosed patients be evaluated carefully pathologically if they’re to be served well. Tell us why this is so important.

Dr. Dennis Weisenberger (Guest): Well, it’s often pathologists who actually make the diagnosis and tell the surgeon or the oncologist whether it’s cancer or not, and specifically what kind of cancer it is. Of course, the type of treatment that the patient will receive often depends critically on these specific diagnoses. That’s why it’s so important to have an adequate biopsy, and to have a second opinion in cases particularly where there are some questions about the diagnosis.

At City of Hope, we routinely review the pathology on all patients who come here for treatment. We also see a lot of consultations from pathologists and other practitioners who send us cases for our opinion. We do also see cases at patient’s request that we review their slides for a second opinion. This is pretty common practice. It is actually part of our strategy for excellence at City of Hope that there is a second opinion on every patient who comes here. It actually does make a difference in how patients are treated at City of Hope.

Melanie: Dr. Weisenberger, tell us about second opinions, because people come to City of Hope for their second opinions and sometimes they learn good, sometimes they don’t. But what about second opinions, are doctors offended when a patient wants one? How do you go about seeking one?

Dr. Weisenberger: I think most doctors are not offended when the patient asks for a second opinion because it’s common practice, particularly in the field of oncology. I think patients should feel comfortable about asking their physicians to request the second opinion. Often the physician will know an expert to send the patient to, or to have the slides sent to an expert pathologist if it’s the pathology diagnosis that they want a second opinion on. So I think patients should feel comfortable requesting that from their clinician. Good clinicians respect the right of the patients to have a second opinion.

Melanie: What happens sometimes when a second opinion is sought at City of Hope? Is there a reversal of diagnosis? Can somebody find out something different than they originally found out?

Dr. Weisenberger: Yes. For routine pathology diagnoses, cancer diagnoses, probably we change the diagnosis in five to ten percent of the cases. In many of those cases, the change in diagnosis will result in a change of treatment. A more specific or a more effective treatment will be given. For my field, hematopathology, that is, diagnosis of lymphoma, leukemia, and blood disorders, it’s even higher. We change the diagnosis in probably up to fifteen percent of cases. In a recent study, we found that in thirteen percent, almost all of those cases, thirteen percent, it was a major change in diagnosis that resulted in a different therapy.

That’s why it’s policy at City of Hope to have these second reviews because we know that mistakes are often made in community, so when patients come here we want to make sure we treat them with the best treatment we have for their specific disease. It’s common practice here. It’s a mandated practice actually to have a second review of pathology slides.

Melanie: And even in some of the more common cancers that we hear so much about—skin cancer, prostrate, breast—sometimes the diagnosis error rate can vary up to forty percent. So tell us about City of Hope, when someone is coming to you for skin, breast, or prostate cancer for a second opinion, what are you seeing there?

Dr. Weisenberger: Well, sometimes the outside diagnosis is right, but maybe the estimation of how aggressive the malignancy will be. So, in prostate cancer, for example, we do something called grading, where we say it is “high-grade,” meaning it’s going to be very aggressive clinically, or “low grade,” meaning it’s not going to be very aggressive clinically. So pathologists look at the slides and they grade the tumor, and sometimes there’s a lot of variation in how pathologists do that. Even with a common cancer, like prostate cancer, often the grade that we will give the cancer is different and that will result in different therapy. The same thing is true of breast cancer. For breast cancer, we do a lot of specialized testing for estrogen receptors and other kinds of receptors.

What we have found is that often our testing differs from the testing at the outside hospital, and so we routinely will repeat some of the tests to be sure that the outside findings are correct, and sometimes they aren’t. Again, that will really dramatically affect how the patient is treated here. So we’re very careful to evaluate the diagnosis, the grading, repeat some of the tests in order to make sure we have the best information for our doctors to treat the patient.

Melanie: Now if a cancer is really hard to diagnose, a rare type, or if the patient wishes to be considered for a clinical trial, is there any difference in the way that you go about pathological reports?

Dr. Weisenberger: No. We pretty much treat all the patients the same. For clinical trials, sometimes we do additional tests which are part of our research program, but we pretty much treat all of the patients the same, whether they’re part of a trial or not. Also, I should probably add that usually most insurance companies and HMOs will cover a second opinion because they do realize the value of the second opinion. Nowadays, some of the treatments are so expensive it could cost up to $80,000 or $100,000 a year for certain kinds of new treatments. So it’s important to make sure you have the right diagnosis because some of the therapies are so expensive and sometimes you can avoid giving the expensive therapy depending on the diagnosis.

The other thing we do sometimes is that sometimes the patient comes with a diagnosis of cancer and when we look at the slides we realize they don’t have cancer. Of course that’s very important for the patient. Those kinds of things happen. That’s another reason to get a second opinion.

Melanie: So in just the last couple of minutes, Dr. Weisenberger, tell people why they should come to City of Hope for their pathology consultation services or their second opinions.

Dr. Weisenberger: Well, in our department, we have expertise in all the various fields of pathology. We have a lot of special expertise in hematopathology. We have the latest equipment, diagnostic testing, molecular testing, to both diagnose and confirm diagnosis and also for prognosis. We’ve got tests that sometimes will speak to the prognosis of the patient. Then we’ve got excellent clinicians in medical oncology, in hematology, in leukemia, lymphoma, in myeloma, breast cancer, prostate cancer. We’ve got excellent clinicians who have a wealth of experience in taking care of patients. We have teams.

The nice thing about City of Hope is it’s a hospital dedicated to cancer, so we are really focused, not just on treating patients but also in doing basic research and clinical research to try to find new treatments. We have new clinical trials. We have new drugs. We have therapies that are not available at other hospitals in the region, and so there are a lot of good reasons to pick the City of Hope for a second opinion.

Melanie: Thank you so much for such great information. Dr. Dennis Weisenberger. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Internal Notes Y
Hosts Melanie Cole MS

Hematologic Cancers: Better Treatments to More People Now

Additional Info

Segment Number 2
Audio File city_hope/1431ch1b.mp3
Doctors Forman, Stephen J.
Featured Speaker Stephen J. Forman, M.D.
Guest Bio Stephen J. Forman, M.D., is an internationally recognized expert in leukemia, lymphoma and hematopoietic cell transplantation and is the program leader for City of Hope’s NCI-designated Comprehensive Cancer Center’s Hematologic Malignancies Program. He serves on the editorial boards of many scientific journals and was recently appointed to the Strategic Planning Advisory Committee of the California Institute of Regenerative Medicine. He is co-editor of Thomas’ Hematopoietic Cell Transplantation, a definitive textbook for scientists and health care professionals.
Transcription Melanie Cole (Host): As a pioneer in advancing care for all hematologic cancers and blood-related disorders, City of Hope’s Department of Hematology and Hematopoietic Cell Transplantation leads the field as one of the largest and most successful transplant centers in the world. My guest is Dr. Steven Forman. He’s an internationally recognized expert in leukemia, lymphoma, and hematopoietic cell transplantation and he’s the program leader for City of Hope’s NCI-designated comprehensive cancer centers hematologic cancers program. Welcome to the show, Dr. Forman. Tell the listeners what are hematologic cancers.

Dr. Steven Forman (Guest): Hematologic cancers are those malignancies that people get that fall in the category of leukemia, lymphoma, and multiple myeloma. These are cancers that arise from the blood and bone marrow and the immune system. We have specific treatments for each of them, including stem cell transplantation where indicated. These are cancers that can be acute; maybe they come on rather rapidly. It can make somebody quite ill and require care sometimes emergently, while others are more indolent and are not as aggressive. I think getting the right treatment for the right disease is an important component of what we do.

Melanie: Dr. Forman, someone gets a diagnosis of a blood cancer, and it can be quite devastating and very scary. What do you tell them right off the bat to start them out on this journey and give them some hope?

Dr. Forman: I think the first thing to do is to give them accurate information about what the disease is because when we cancer in general, and even leukemia specifically, it’s very alarming. It’s very emotional. So we try to explain what it is that they have and, more importantly, what we’re going to do about it. I would say for almost all of the cancers of the blood and immune system, there is effective treatment. I think that when a person knows that they have the chance for either good therapy treatment or even cure, it goes a long way towards helping them partner with us to aid in getting them completely well and returning them to their home with their family and their friends, their community, which is what our goal is.

Melanie: Dr. Forman, City of Hope’s patient outcomes are among the best in the nation. Tell us a little bit about cell transplantation, what that involves for both the patient and the donor. Because people hear about bone marrow transplantation; they get scared, they’ve heard it’s painful. Tell us about it and kind of clear it up for everybody so it’s not so confusing.

Dr. Forman: So among the therapies that are done for treatment of cancers of the blood and the immune system is stem cell transplant, which is a way of basically replacing a person’s diseased bone marrow and diseased immune system with someone’s who is healthy. It’s a challenging procedure and requires the cooperation of not just family but many, many of our staff to to pull it off. The one that you’re asking about is when we use donor cells from matches that we determine either in the family or outside the family where we basically give a therapy that eliminates a person’s blood and immune system and then we replace it with cells derived from either a family donor or an unrelated donor. In essence, we convert a person’s blood and immune system into somebody else’s. It’s an organ transplant not unlike heart, lung, liver, kidney transplants, except this is the blood and immune system.

The goal is not just to make the switch but to use that switch to eliminate the disease that the person had in the first place. Depending upon how extensive the disease is, that determines the intensity of the approach we use to do the replacement therapy. For the donor, for the most part, it is a procedure that involves taking a stem cell from the blood stream so that it’s not so different than donating blood or platelets. It’s a little bit more involved because one is on the machine a little longer. We collect the stem cells from the blood stream and then infuse them intravenously into the patient. The stem cells dramatically, in some ways, find their way into the right place in the bone marrow, set up shop, and begin to produce blood and immune cells as it did from the donor.

In some cases, we actually do go into the bone marrow of the donor, and that’s done in about a thirty-minute procedure in the operating room where we take marrow out and put it in, again, trying to get the stem cells to the right place which invariably always happens. That donor becomes, in essence, a family member. We have close to 11 million people in the United States who are on the registry, who have volunteered to be a donor should a patient need a transplant and not have a match within their family.

Melanie: Dr. Forman, how long does it take for the patient to notice a difference, or for you as a doctor to know if this treatment is working and that donor cells are working?

Dr. Forman: The first indication is, after the chemotherapy or radiation that the patient gets to prepare them for the transplant and we then put in the cells from the donor—it takes about two weeks—the blood counts which go down very low will begin to rise towards normal. When we see that happening, it’s a very good indication that there’s been a so-called “take,” or engraftment is the word that is used. Then we do some fairly elegant tests to prove that the cells are growing, not the patient’s but rather the donor’s stem cells given to the patient.

It gets as quirky as even though we do certain matching between patients and their donors, the blood group doesn’t have to match. If you were blood group A as a patient and your donor was blood group O, you’re going to switch over to blood group O for the balance of your life. We have converted you into the person who gave you the cells. But the rising of the counts is the best proof that the “take” has been there, and that will be the person’s blood and immune system for the rest of their life.

Melanie: Wow. That’s cool that you’re blood type actually changes from that. Now tell us a little bit about the group of cancers known as lymphoma. We hear about various celebrities that have come up with it, and there are a couple different types. Yes?

Dr. Forman: Yes. There are different types of lymphoma, and there are different types of leukemia. In lymphoma, it ranges from a disease that can be very indolent and sometimes does not even need much treatment at the beginning, to a disease that is highly aggressive and a person comes to you quite ill and needs to be hospitalized that day. It shows you that the word lymphoma can be somewhat all encompassing. The first thing we have to do is figure out what type of lymphoma the person has as that will dictate the treatment.

Increasingly, the treatment regimens are very specific for the type of cancer that the person has, and in this case lymphoma. So not all of lymphoma is treated the same. One thing that we spend a lot of time on here is just making sure that the diagnosis is correct. I think the number I saw recently as we correct or modify the diagnosis is about thirty percent of the time. So coming here or coming to any major cancer center, part of their job is really to make sure that what the person was told they have is in fact what they have because it does guide treatment. The therapy can vary from everything from antibody therapy against the cancer to full-fledged, full intensive chemotherapy to stem cell transplant. We try to figure out what is the most appropriate therapy for that particular moment for a patient. The last few years have just seen an explosion of new approaches, new therapies, and when I think back on what we were doing just ten years ago and what we’re doing now, I can see differences. I can see we’re doing better for people now than we did before, and it makes us hungry and aggressive to want to find out more to be able to do more.

The same thing applies to acute leukemia where you can have diseases that can be somewhat indolent and don’t need a lot of treatment, to diseases like acute leukemia that require basically hospitalization literally that day in order to be able to save somebody’s life.

Melanie: And, Dr. Forman, in just the last minute that we have left, tell us about the recently launched Hematologic Malignancies Institute and why people should come to City of Hope for their hematologic cancer care.

Dr. Forman: I think City of Hope has a rich history in both developing therapy for and taking care of people who have these somewhat unique diseases. I think when they come here they really have the whole repertoire of therapies at their disposal, and so they don’t have to go someplace else. So if you need a transplant, you can get a transplant. If you need standard therapy, you can get standard therapy. If you need investigational therapy, there’s a very deep and rich clinical trials network here, which really, because we have taken the ideas we have in our laboratory and put them into practice so that we can help patients who might need them.

Another aspect, I think, here, in addition to making the correct diagnosis and our pathology department which is also quite experienced, is that the nurses in this institution are very attuned to taking care of patients with cancer, and particularly patients with these diseases, in a very respectful and dignified way. I think one of the things we hate about cancer is that it’s a thief, not just of life but of the quality of people’s lives and their integrity. So for us, they are people who have cancer; they’re not cancer patients. I think the combination of a respectful environment with science that drives our compassion and our wanting to do a better job today than we did yesterday, I think, makes it a unique place for people to come here and know they’re going to be cared for well.

Melanie: Thank you so much, Dr. Steven Foreman. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks for listening.
Hosts Melanie Cole MS

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