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Encouraging screening in underserved populations Health advocates and policymakers want to reach those who haven’t been screened, especially those with low incomes and limited access to pri-mary care.

Through its FIT-flu program, MD Anderson collaborates with community health clinics like Access Health in Richmond, Texas, to make screening tests available to qualified clients.

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By Mary Brolley

Lewis Foxhall, M.D., doesn’t mince words about colon cancer, which is expected to cause more than 50,000 American deaths in 2014. “If the disease is caught and treated in its

early stages, the overwhelming majority of

patients survive. In fact, they do well,” says

Foxhall, professor of Clinical Cancer

Prevention and vice president, Office for

Health Policy.

But too many are diagnosed and start

treatment at the late stages of disease, he says.

“At that point, good outcomes are much more

difficult to achieve.”

“It’s that stark.”

Colorectal cancer is the second leading

cause of cancer-related deaths in men and

women, according to the American Cancer

Society.

How can we catch this deadly cancer early? In contrast to other well-established cancer screening tests — the PAP for cervical cancer, the mammogram for breast cancer, and skin checks for skin cancer — the colonoscopy, recommended to screen for colon cancer, is more of an ordeal.

It’s relatively expensive and requires dietary changes and hours of preparation.

Yet, because it’s so effective in catching colon cancer at early, treatable stages, it’s considered the gold standard in colon cancer screening.

Still, only half of eligible Americans have any type of screening test for colon cancer.

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Lifeline: Community-based program increases access to colon cancer screenings

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It’s an evidence-based intervention, Vining says. “Research has proven that this test reduces incidence and mortality associated with colon cancer.”

If successful, the FIT-flu program could be used across Texas and beyond to increase cancer screening and reduce the chance that people will die from this disease.

“The best screening test is the one that gets done,” Foxhall adds. “I tell my patients they should aim to die young — as late in life as possible,” he jokes.

The program is available to low-income, uninsured, Medicaid or Medicaid-eligible adults age 50 to 75. It’s funded by a grant that allows communities and hospitals to form regional partnerships that support more localized health care solutions.

Since last fall, more than 500 clients have picked up a FIT test when they came to the clinic for their flu shots.

Also called a fecal immunochemical test, the FIT checks for blood in the stool, which can be a sign of colon cancer before any symptoms develop. The test is offered in conjunction with the annual flu shot as a convenient time to remind eligible people to get tested.

A positive test spurs a referral for a free colonos-copy test. If cancer treatment becomes necessary, FIT-flu program staff work with the Access Health team to find resources for the patient’s treatment.

So far, more than half of the 522 tests distributed have been mailed back to labs for testing, says Daniel Pacheco, program coordinator for the FIT-flu program. At least 18 tests have been positive, and two people were diagnosed with early stage cancer after further testing.

Who’s more likely to get colon cancer? The lifetime risk of getting colon cancer is about one

in 20. Factors that increase the risk include:

• age,

• a history of polyps,

• a family history of colon cancer,

• inherited syndromes such as familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal cancer (HNPCC), and

• inflammatory bowel disease

Racial and ethnic background, having Type 2 diabetes, and lifestyle factors like poor diets and inadequate physical activity may also increase risk.

‘The best screening test is the one that gets done’ The program will distribute 2,000 FIT-flu tests during flu season through 2015.

The partnership is “a stroke of genius,” Foxhall says.

David Vining, M.D., agrees. A professor of Diagnostic Radiology, he spearheaded the program with funding from a CPRIT grant in 2010.

“Community health clinics offer a great avenue for distributing the test,” he says. “Colon cancer is a largely avoidable type of cancer, if people get screened.”

MD Anderson’s screening guidelines for colon cancer:

At age 50, men and women at average risk* with no colorectal cancer symptoms should follow one of these schedules:

• Fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year. This take-home test finds hidden blood in the stool, which may be a sign of cancer. If blood is found, a colonoscopy will be performed.

• Virtual colonoscopy (also known as CT colonography) every five years. If polyps are found, a colonoscopy should be performed. Check with your insurance provider to see whether this exam is covered.

• Colonoscopy every 10 years. Preferred by MD Anderson; polyps can be removed during test.

*Individuals at higher risk should talk to their physician about an appropriate testing schedule. Higher risk may be due to hereditary factors, for example.

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“Art gives them the most important thing of all — hope,” De La Rosa says.

When he calls a patient he’s been matched with, the conver-sation often starts slowly, he says.

“Most of them don’t know what to ask. They’re still coping with the shock of their prostate cancer diagnosis.”

But soon the men start talking and comparing notes.

“They tell me things they don’t feel comfortable telling their doctors or their wives,” he says.

“I don’t coddle ‘em. I don’t say, ‘Poor you.’ I joke with them. And I don’t give them false hope. I tell them the facts.”

Herzog has also volunteered at Anderson Network’s Cancer Survivorship Conference for many years.

Easing nerves with a welcoming presence

Perhaps most memorably, Herzog was a counselor at Anderson Network’s CareFree Retreat for nine years. He arrived early on his motorcycle to check that the cabins were clean, the air conditioning turned on and coffee available for the patients.When the campers — some of whom were quite nervous about the whole experience — arrived at camp, they were greeted by Herzog dressed as a leather-clad, tattooed motorcyclist with a long black wig.

His unexpected and humorous welcome never failed to ease the nerves of the campers.

Gasper Mir, who volunteered with Herzog at the Carefree Retreat, quickly recognized his love for helping others, selfless attitude, friendliness and sincerity.

“Once you know Art, you know him,” Mir says.

To learn how to connect with a cancer survivor through the Anderson Network, call 800-345-6324. The 2014 Cancer Survivorship Conference is Sept. 19-20.

Prostate cancer survivor spreads positive outlookBy Erin Pisters and Mary Brolley

originally published in Cancerwise, MD Anderson’s blog

Although some cancer survivors distance themselves from cancer after treatment, Art Herzog has taken another route. Diagnosed with prostate cancer in March 1990, he weath-ered radiation therapy with the love and support of his family and doctors.

Even after three recurrences, Herzog’s positive outlook on life — and cancer — is contagious.

Giving back to other prostate cancer patients The prospect of improving other patients’ experiences has always been important to Herzog.

For 22 years, he’s been an active and devoted volunteer with the Anderson Network, a community of more than 2,000 cancer patients and survivors who share their experiences, advice and encouragement with other patients facing similar obstacles.

Matched by age, diagnosis and treatment, prostate cancer patients know they can count on Herzog to answer their ques-tions or concerns.

“When our staff contacts Art to see if he’s available to be matched, he never hesitates,” says Laura De La Rosa, program coordinator for Anderson Network.

“He puts patients or caregivers at ease, no matter how tough the diagnosis. He calms their fears and shares his own experi-ence. He reminds them that if he can do it, so can they.”

Providing hope and facts

In 2013, Herzog earned the Painter Award, given annually to an Anderson Network volunteer who’s made exceptional contributions to patient networking activities and support.

Anyone who’s met Herzog can quickly understand why he received this honor: This warm, funny and sympathetic man has become a source of strength and support for many men battling prostate cancer at MD Anderson and beyond.

people profile

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How are emergency medicine and palliative care related? Daily experience in our nation’s emergency departments suggests that those complex life-limiting illnesses are often caught in a revolving door of care that may fail to address indi-vidual patient goals. Too often, those with terminal illnesses are treated for the most immediate problem without being offered comprehensive supportive care to ease distressing symptoms, improve coordination of services and provide caregiver relief.

Increasing numbers of emergency physicians are receiving specialized training in hospice and palliative medicine. Our staff has particular expertise in recognizing the need for pallia-tive care, hospice and caregiver support services in those with advanced cancer. Working with our palliative care colleagues and local hospice facilities, we try to provide the highest quality of care for our patients.

Why did you come to MD Anderson? Like most MD Anderson faculty members, I was attracted by the excellent faculty and superb facilities.

Also, I came here because of the large numbers of cancer patients who seek our treatment. There is simply no emergency department in the world with the wealth of experience our patients bring us. It’s a tremendous privilege to work here.

doctor, doctorFocus on: Emergency Medicine

We asked Knox Todd, M.D., professor and

chair of Emergency Medicine, to tell us how

his department helps MD Anderson patients.

Todd’s research interests include the intersec-

tion of emergency medicine and palliative care.

What do physicians in the Emergency Center do? Emergency physicians in our department staff the Emer-gency Center 24 hours a day, seven days a week, 365 days a year. We expect to treat 23,000 patients this year, and our patient volume grows every year.

Though we see the occasional family member or employee in need of emergency care, more than 90% of our patients are undergoing active treatment at MD Anderson.

Patients come to us for the diagnosis and management of symptoms related to cancer or its treatment. These include pain, shortness of breath, nausea, infection or bleeding. While MD Anderson has a large number of physicians and centers specializing in specific types of cancer, emergency physicians see cancer in all its forms. In fact, one-half of all patients hospi-talized here are admitted through the Emergency Center.

Why is emergency medicine so important to MD Anderson patients? Emergency medicine has been a distinct medical specialty in the United States for more than 40 years. Most departments were established because patients required sophisticated, time-sensitive diagnosis and treatment services that were simply not feasible to provide through subspecialty services or facilities.

How has your department grown? We began in 2010 with a dozen faculty and staff. We now have more than 50 clinical and research staff.

All large academic health centers offer specialized emer-gency medicine care and training. But MD Anderson is the first comprehensive cancer center with an academic department of emergency medicine.

Knox Todd, M.D.

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Ibrutinib and rituximab trigger 95% response rate among CLL patients

Nearly all the high-risk chronic lymphocytic leukemia (CLL) patients in a Phase II clinical trial responded to treatment with the targeted therapy ibrutinib and the antibody rituximab, MD Anderson researchers reported in December at the 55th Annual Meeting of the American Society of Hematology.

CLL is a malignancy of immune system B cells, white blood cells that normally produce antibodies against infection. Ibruti-nib blocks Bruton’s tyrosine kinase (BTK), a vital component of B cell receptor signaling.

The combination of ibrutinib and rituximab produced complete or partial responses in 38 of 40 (95%) high-risk CLL patients. At a median follow-up of 18 months, 31 patients (78%) remained on the drug with no sign of progression, with overall survival at 84%.

“This combination improves on the already excellent response rate from ibrutinib alone, which is usually around 70-80%. It’s also well-tolerated, with manageable side effects, and significantly improves patients’ quality of life,” says Jan Burger, M.D., Ph.D., associate professor of Leukemia.

The faster, improved response rate, Burger says, is most likely due to rituximab addressing an early effect of ibrutinib treatment — temporarily higher counts of white blood cells and leukemia cells during the first months of treatment.

Burger’s earlier research showed that this effect occurs because ibrutinib breaks ties that allow leukemia cells to hide out in the bone marrow and in lymph nodes, pushing them out into the bloodstream. Rituximab picks off these now more vulnerable CLL cells.

Similarities in molecular profiles of invasive bladder cancer, breast cancer

Researchers who took a fresh look at muscle-invasive bladder cancer through the lens of gene expression found that it looks remarkably like breast cancer. This has important implications for treating the most lethal form of bladder cancer.

MD Anderson scientists reported in the February edition of Cancer Cell that the gene expression profiles of advanced bladder cancer fall into three molecular categories that closely resemble three of the four major subtypes of breast cancer.

These similarities point to possible chemotherapy guidance and targeted therapy for high-grade disease, says study senior author David McConkey, Ph.D., professor of Urology.

“There are no targeted therapies for this high-grade cancer now, so a future implication of these findings is developing new, better approaches for treating our patients,” McConkey says. Characterization of breast cancer is more advanced, with tar-geted approaches available for three subtypes and chemotherapy advised for the fourth.

Muscle-invasive disease makes up about 30% of bladder cancer cases, but causes the vast majority of deaths. Treated with chemotherapy, surgery and radiation, the disease will kill about 15,000 Americans this year.

A multi-institutional prospective Phase II clinical trial for muscle-invasive bladder cancer will allow an even more rigor-ous assessment of the subtypes’ clinical value to guide therapy. Led by the Southwest Oncology Group, the trial will open soon, McConkey says.

To learn more about MD Anderson research, visit www.mdanderson.org/newsroom or the Cancer Frontline blog at www2.mdanderson.org/cancerfrontline.

research briefs

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Graft-versus-host disease: Battle of the cells

By Mary Brolley and Judy Overton

Multidisciplinary care is the cornerstone of treatment at MD Anderson.

This team approach means that patients may see oncologists and general internists, as well as specialists in cardiology, pulmonary medicine, dermatology and more.

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The partnership is based on the premise that recognizing the disease early is key. Then, prompt therapeutic intervention may prevent progression to higher-grade disease, improving outcomes for stem cell transplant patients.

“When we see a patient who has GVHD, especially acutely, we look at their skin to make sure there isn’t a rash,” Hymes says. “If the patient does have a rash, we document how widespread it is, and exactly what it looks like.”

“The reason a patient develops chronic GVHD is less understood,” she says. “It may be a disorder of immune regulation. But even so, the skin can show a multitude of changes that aid in the diagnosis of the disease.”

Patients with a milder form of GVHD may be treated with topical (applied to the skin) medications, Hymes says. The development of blisters, however, indicates more serious disease and often prompts physicians to use systemic (throughout the body) therapy.

Hymes says there are currently a multitude of clinical trials for both acute and chronic GVHD at MD Anderson. The trials are not only trying to determine the best treatment for the disease, but are also working to regulate the anti-tumor effect that can occur in the setting of GVHD.

“That’s the dilemma,” Hymes says. “Patients with GVHD may also experience an anti-tumor effect that decreases their chance of relapse.”

“By learning more, we may be able to harness these reactions of the immune system and induce and maintain remissions.”

Sharon Hymes, M.D.

For patients whose bone marrow has been destroyed by cancer or its treatment, stem cell transplants are a growing option. The transplants are intended to replenish blood-producing stem cells and restore the patient’s health.

In 2011, nearly 18,000 stem cell transplants were performed in the United States, according to the U.S. Department of Health and Human Services.

In this area of treatment, dermatology — the science of diagnosing and caring for skin disorders — plays a crucial role in monitoring and safeguarding recipients’ health after transplant.

Lifesaving treatment: a delicate balance Of the more than 1,000 transplant procedures performed at MD Anderson each year, roughly half are autologous (using the patient’s own cells) and half are allogeneic (using cells from a donor).

Donors may be related to the patient or not, but the closer the match to the patients’ cells, the better the transplant is likely to go.

But they don’t always go smoothly.

A common complication of allogeneic transplants is graft-versus-host disease (GVHD). Its effects range from mild to severe, and the disease may even cause death. When MD Anderson patients develop skin disorders after an allogeneic stem cell transplant, they can see dermatologist Sharon Hymes, M.D., who monitors and manages complications of cutaneous GVHD in the Stem Cell Transplantation and Cellular Clinic.

In the brave new world of stem cell transplantation, nothing is simple. Recipients may be on a variety of medications. They are likely to have comorbidities (other health conditions). And early symptoms of GVHD reactions are similar to post-treatment side effects.

Hymes first became intrigued with the disease during her medical training, and later as a resident at Johns Hopkins Hospital.

There are two forms of GVHD, acute and chronic.

Acute GVHD disease begins two to six weeks after transplantation. It occurs when immune cells in the tissue (graft) identify tissues of the patient (host) as foreign or different, and selectively damage the skin, gut, liver or lungs.

Chronic GVHD develops later, and is not as well understood. It may occur after the acute form of the disease, or to those who haven’t had it yet.

Partnership helps patients recover When Hymes joined the dermatology unit at MD Anderson in 2001, GVHD complications became her area of expertise. She sought out Richard Champlin, M.D., chair of Stem Cell Transplantation and Cellular Therapy, who was receptive to the idea of a joint venture oncology-dermatology clinic designed to treat the disease.

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The Anderson Network is a program of Volunteer Services at MD Anderson Cancer Center.

Address changes should be sent to: Mary Brolley The University of Texas MD Anderson Cancer Center 1400 Pressler St. - Unit 1486 Houston, TX 77030-3722 Phone: 713-792-0658 Fax: 713-745-1875 Email: mbrolley@mdanderson.org

Articles and photos may be reprinted with permission.

Susan French, Executive Director, Volunteer Services Debbie Schultz, Assistant Director, Volunteer Services/ Anderson NetworkAshma Moosa, Chair, Anderson Network Mary Brolley, Writer/Editor, NetworkJudy Overton and Erin Pisters, Contributing WritersGini Reed, Graphic Design

© 2014 The University of Texas MD Anderson Cancer Center

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Would you consider sharing your cancer experience with a newly diagnosed patient or caregiver? If so, call the Anderson Network at 713-792-2553 or 800-345-6324, and learn how to become a member of our one-on-one support program. It connects patients and caregivers dealing with similar diagnoses and treatment plans.

Especially needed are those who’ve experienced:

• Lung cancer

• Gastrointestinal cancers: liver, colon

• Head and neck cancers

• Ovarian cancer

We’re also looking for cancer survivors with ostomies and those who speak languages other than English, especially Spanish.

Your story and willingness to listen could make the difference in another person’s ability to cope with their diagnosis and treatment. The Anderson Network motto is: “Sometimes the best help comes from someone who’s been there.”

www.mdanderson.org/andersonnetwork

One-on-one support program needs your help