Du k e C a n c e r Institute mem-

ber Paul Modrich, PhD, was awarded t h e 2 0 1 5 N o b e l Prize in Chemistry.

Modrich is also a James B. Duke profes-

sor in the Department of Biochemistry at Duke

University School of Medicine and a Howard Hughes Medical Institute investigator.

He shares the prize with Aziz Sancar, MD, PhD, of the University of North Carolina at Chapel Hill, and Tomas Lindahl, FRS, FMedSci, of the Francis Crick Institute and Clare Hall Laboratory in the United Kingdom.

According to the Nobel Foundation, the three scientists, working independently, have revealed how cells repair damaged DNA, which is vital knowledge about how a living cell functions. That knowledge is used for the development of new cancer treatments.

Modrich’s work showed that when cells divide and DNA is copied, which happens millions of times a day, copying errors can occur, but that the body can repair them. He demonstrated how the human body recognizes and repairs those errors, in a process called DNA mismatch repair.

In addition, Modrich demonstrated that inac-tivation of the DNA mismatch repair pathway is the cause of the most common form of heredi-tary colon cancer, called Lynch syndrome.

Modrich has spent 40 years studying DNA repair, much of it at Duke. He joined the Department of Biochemistry in 1976. Modrich earned his bachelor’s degree at MIT in 1968, and a PhD at Stanford University in 1973. He is a fellow of the American Academy of Arts and Sciences and a member of the National Academy of Medicine (formerly the Institute of Medicine) and the National Academy of Sciences.

FALL 2015

Will Eward, DVM, MD, works to find better treatments for a cancer called sar-

coma. It makes no difference to him that half of his patients walk on four legs and bark at the doorbell.

Eward, an assistant professor of orthopaedics,

spends the first part of his week treating dogs at Triangle Veterinary Referral Hospital, and the second half treating people at Duke Cancer Center. “When it comes to cancer, it really doesn’t matter if you have fur or skin or feathers,” he says. “It’s the same disease.”

Sarcoma is rare in humans, but when it strikes, it’s often lethal. It’s much more common in dogs. In his early days as a full-time small animal veterinarian, Eward saw so many dogs with sarcoma, he became frustrated with the lack of good treatments. So he went to medical school to launch a full-scale fight against the disease in both species.

A few other cancer specialists, including D u ke ’s M a rk D e w h i r s t , DV M , P h D, Gustavo S. Montana Professor of Radiation Oncology, have believed in this idea, called “Comparative Oncology” or “One Medicine,” for more than 40 years. Increasingly, scientists are taking notice. The approach is behind a new formal partnership between Duke Cancer Institute and the College of Veterinary

Medicine at North Carolina State University. The Consortium for Comparative Canine Oncology (C3O) will formally bring together cancer doctors and researchers at the two institutions and will fund research projects that include both. Dewhirst and Eward are members of the C3O steering committee at Duke, as is Neil Spector, MD, Sandra K. Coates Associate Professor of Medicine.

HELPING DOGS TOO

Many new cancer medications are first tested in research animals, such as mice that are bred to get cancer. But studying that same drug in a

pet dog who developed cancer naturally is much closer to studying it in a human. “Because of a dog’s size, you can do dosing that’s more like dosing in a human,” Dewhirst says. And, dogs get cancer as they age just like we do, so pets in clinical trials may have other illnesses, like diabetes or heart conditions, making the results more realistic, he adds.

In addition, the idea of “dog years” is true

The Answer on the Other End of the LeashCan our best friends help us develop better cancer treatments? by Angela Spivey

Paul Modrich Wins Nobel Prize in Chemistry

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Will Eward and Cindy Eward with their dog, Pete.

Paul Modrich’s 40 years studying DNA repair revealed the causes of the most common form of hereditary colon cancer as well as many other types of tumors.

DUKE RESEARCHERWINS NOBEL PRIZE

IN CHEMISTRY >>

Support DCI’s next pioneering researcher: visit gifts.duke.edu/dci or call 919-385-3129.>

When it comes to cancer, it really doesn’t matter if you have fur or skin or feathers. It’s the same disease. – Will Eward, DVM, MD

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for cancers, too, Eward says. For instance, he may find out the ultimate outcome for a dog with sarcoma in two years; in a person it could take ten. So trials in pet dogs may reveal how well new therapies prolong survival faster than human trials.

What pet owners want is to help their dogs, and comparative oncology should do that, as well. Half of all dogs over the age of 10 die of cancer. Increasingly, dog owners are willing to treat them for cancer and even enroll them in clinical trials of new therapies. The veterinary clinic where Eward works offers clinical trials, as does the NC State veterinary school,

which is one of 20 canine oncology clinical trial centers around the country, managed by the National Cancer Institute, that pool results about new cancer therapies. “Trials in humans and in dogs should inform each other,” says Michael Kastan, MD, PhD, execut ive director of Duke Cancer Institute and William W. Shingleton, MD, Professor of Pharmacology and Cancer Biology. (In 2015, Kastan chaired the planning committee for a national panel on compara-tive oncology, sponsored by the National Academy of Medicine.)

TARGETING CHEMOTHERAPY

Duke has a long track record in comparative oncology, thanks to Dewhirst. A veterinary radiation oncologist, he came to Duke in part because of its proximity to potential collaborators at NC State’s veterinary school. He and colleagues there conducted clinical trials of new therapies in pet dogs

starting in the 1980s, yielding valuable informa-tion about dosing and possible complications. That was the case with a technology that Dewhirst and Duke biomedical engineer David Needham, PhD, developed to target a potent chemotherapy directly to tumors. Patients receive a drug encased in liposomes (bubbles made out of fat) that dissolve only when heated. Then heat is applied to the tumor only, and the liposomes release high doses of the drug exactly where it’s needed.

The technology worked in mice, and in 1999, a company called Celsion bought the rights to it. They agreed for Dewhirst and Donald Thrall,

DVM, an NC State veterinarian, to test it in trials with pet dogs. “One of the very first dog patients we ever treated had an anaphylactic reaction,” Dewhirst says. “The dog’s face swelled up after we gave the drug. We realized that they’re going to have to be pretreated with steroids and antihistamines.” The researchers were able to quickly treat the reaction in that first dog. “He did okay,” Dewhirst says. “And that regimen that we developed in the dogs ended up being what’s used in humans to prevent that kind of reaction.” The technology, called Thermodox, is being tested in late-stage clinical trials in people with liver cancer.

SEEING SARCOMA

More recently, Eward moved a new imaging technique for sarcomas into a human clinical trial because he showed that it worked well in pet dogs with the disease. Surgery can cure sarcoma, but only if the surgeon removes all of it. “It can be really hard to tell where the last cancer cell is,” Eward says. “If there are any cancer cells

Oncologists Will Eward and Cindy Eward demonstrate an orthopaedic exam with their dog, Virgil. Will Eward treats both people and dogs with cancer.

Radiation oncologist Mark Dewhirst and NC State veterinarian

Donald Thrall with a pet dog who participated in one of their

many clinical trials of new cancer therapies.

Notes is produced two times a year by Duke Cancer Institute Office of Development 710 W. Main Street, Suite 200Durham NC, 27701 • Phone: 919-385-3120

Kathi Dantley Warren Executive Director of Development, Duke Cancer Institute

Marty Fisher Executive Editor

Angela Spivey Editor/Writer

Carol Harbers Writer

Karen E. Butler Writer

Dave Hart Writer

Bernadette Gillis Graphic Design

Photography: Duke University Photography; Shawn Rocco, Duke Medicine; Jim Rogalski; Karen E. Butler

If you would like to remove your name from the mailing list or are receiving duplicate copies, please email dcidevelopment@duke.edu, or contact us through U.S. mail at the address above or by phone at 1-800-688-1867.

Produced by Duke Medicine Development and Alumni Affairs ©2015 Duke University Health System.

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that are still out there in the body, they’ll grow a new tumor. Sarcomas do this to a greater extent than the more common cancers.” So he and colleagues Brian Brigman, MD, PhD, and David Kirsch, MD, PhD, teamed with scientists at MIT to develop a technology to reveal every last sarcoma cell. The patient gets an IV of tiny fluorescent probes that glow when they come into contact with certain enzymes that are present in soft tissue sarcoma. When the glow is gone, so is the cancer. The technique worked well in mice. But when the researchers applied to the U.S. Food and Drug Administration (FDA) to test the device in humans, they were told they needed to do years of additional testing in laboratory animals first.

Eward, who owns four dogs himself, decided to go another way. “The idea that we would ignore pet dogs with cancer and try things on

healthy laboratory dogs is just a wrong-minded approach,” he says. So Eward and colleagues, including his wife, Cindy Eward, DVM, orga-nized a trial to test the imaging device in pet dogs who were having sarcoma surgery. The trial took place at their veterinary practice and at Tufts University. “It worked great in these dogs,” Eward says. When the imaging tech-nique showed that all the tumor was gone, the pathology test after surgery confirmed it. And it was safe; the dogs with sarcoma had no adverse effects from it. “Because of this trial in pet dogs, the FDA gave us the green light to go ahead with a phase 1 human clinical trial,” Eward says. That trial, which tested the safety of the technique, is complete. The team plans to enroll human patients in a phase 2 trial in early 2016.

THE GENES WE SHARE

Moving forward, researchers are excited about the possibility of applying newer targeted therapies in dog trials. Pet owners are likely to be especially interested in these therapies, which are less toxic than traditional treatments, says Kastan. And the pets could help scientists find biomarkers that measure when a targeted therapy is hitting its mark.

In addition, pet dogs may help reveal previ-ously unknown cancer-causing genes. Eward believes that the most important genetic muta-tions will likely be those that are found in both dogs and humans. “If you look at a sarcoma, you will have thousands of mutations. You’re overwhelmed with information,” he says. “But if

we find that a certain type of sarcoma in a dog and the same type of sarcoma in a human have only four mutations that are common between them, those are probably the driver mutations.”

Kastan agrees that sequencing and analyzing the genetic mutations of cancers in dogs is a priority. He especially sees value in doing that with certain breeds, such as golden retrievers, that are more likely to get certain types of cancer. “Many of the genes that we know about that cause cancer in humans, like the BRCA genes in breast cancer, were discovered by studying fami-lies that have a high predisposition to cancer. When a particular dog breed gets a high rate of a particular cancer, it means there’s something about their genetic makeup that’s predisposing them,” Kastan says. “So studying them is like studying a family.”

Pet owners—81 percent of whom consider their pets as family members—would likely agree.

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Kathy and Michael Kastan at home with their goldendoodles, Micah and Maggie.

Breast cancer survivor Linda Suitt

Linda Suitt stepped out for the 2015 Making Strides Against Breast Cancer walk held at North Hills Mall, in Raleigh, on Saturday, Oct. 17. Suitt, who was diagnosed with breast cancer in 1993, was treated at Duke Cancer Institute. More than 1,700 individuals registered for this year’s American Cancer Society walk, which, to date, has raised almost $200,000. Duke Cancer Institute teams have raised $17,276.

Funds support scientific research for better treatments and a cure and provide for vital programs and services offered to breast cancer patients across the nation. The American Cancer Society is currently investing more than $7.4 million in research grants at Duke. Fundraising continues through December 2015.

To pledge your support to one of our 11 Duke Cancer Institute teams, visit tinyurl.com/qdjldnm.

Pretty in Pink by Karen E. Butler

Innovations lead to better cancer treatments. Support DCI by visiting gifts.duke.edu/dci or calling 919-385-3129.

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d u ke c a n c e r i n s t i t u t e . o r g | DUKE CANCER INST ITUTE NOTES · 3

Helen Wadford’s cancer survivorship story is so remarkable, it had become the stuff of

legend. “I heard you gave one of your patients a pill and she sang at church that evening,” said a new lung cancer patient to Jennifer Garst, MD, director of oncology clinical research and professor of medicine at Duke Raleigh Hospital. The patient didn’t know Wadford personally, but knew her story.

Although Wadford’s triumph over cancer wasn’t quite that simple, it was dramatic enough to hearten those faced with the disease.

In January 2012, the 56-year-old Louisburg, North Carolina, resident noticed a cough that she assumed was…a cough. Months later, the cough was still there, and she felt terrible. A CT scan confirmed the worst: non-small cell lung cancer, stage 4.

CLEARING THE AIR

For many people, hearing of a lung cancer diagnosis leads to the assumption that the patient is or was a smoker. Not true for Wadford—or for 15 to 18 percent of all lung cancer diagnoses. “This is not your grandfather’s lung cancer,” Garst says. “The percentage of people with lung cancer who have never smoked has been slowly growing over the past 10 years.” The alternate cause? For some, it is a genetic mutation.

The silver lining to a genetic mutation is that there are now targeted drugs to treat these lung cancers. Targeted therapies can be very effec-tive, with fewer side effects.

“Chemotherapy is like a cluster bomb,” Garst explains. “It kills the cancer, but it kills healthy cells as well. Targeted therapies are like heat-seeking missiles. They attack the tumor cells directly and have fewer side effects. We routinely test all lung cancer specimens for specific genetic mutations. If the mutation is present, targeted therapy is better than chemotherapy.”

WHAT A PILL!

The thoroughness of her first appointment with Garst took Wadford a bit by surprise. “I met with all the people on the lung cancer team,” she says. “They were remarkable, over the top.” Garst told her then that she wanted to test her for the genetic mutation.

Wadford tested positive and was treated with the drug erlotinib. “When Dr. Garst came in to tell me I had tested positive, she was beaming,” Wadford says. Instead of infusions, Wadford took a pill every day, beginning in September 2012. She did not lose her hair, although it did thin. She developed a temporary rash on her chest and face.

By November 2012 , Wadford was in remission. She got this good news in the morning—that afternoon there was to be a benefit put together by her friends. Garst gave her prints of two X-rays of her lungs: the one from her first appointment and the current one. As she and her husband drove to the benefit, Wadford says, “I was about to bust open with the good news. My husband showed those X-rays around as if he was showing a newborn baby.”

And yes, she did sing at church—a solo—two days after the benefit.

THE NEXT GENERATION

Now a three-year survivor, Wadford continues to do well. In early 2015, Garst began

to see some resistance to the erlotinib, and suggested a trial of a new drug. “New research means great improvements in genetic drugs,” says Wadford. “She wanted to be proactive, and I was all for it.”

A biopsy was required before enrollment in the trial, and by the time her test results came back, Duke’s trial had enrolled the maximum number of participants. But Garst offered

another option. “She asked how I would feel about traveling to Emory to enroll there, since their trial was not yet full,” says Wadford. “My husband and I are retired, so it was not a problem.”

Since February, Wadford has been taking the targeted, experimental drug known as

AZD9291, an epidermal growth factor receptor inhibitor. “Dr. Garst calls this drug ‘the new kid on the block,’” says Wadford. “She keeps in close contact with my doctors at Emory. I feel wonderful. I take a pill every morning at 6:00 a.m. I’ve had no side effects at all. I do every-thing I want to do.” For Wadford, this includes showing up at every ballgame her grandchildren play in, and lots more singing.

Singing the Praises One woman’s uplifting story of beating lung cancer by Carol Harbers

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A targeted therapy fights lung cancer for three-year survivor Helen Wadford. “I do everything I want to do,” she says.

Support our next-generation care: give online at gifts.duke.edu/dci or call 919-385-3129.

Kimberly Blackwell, M D, professor of

medicine and director of t he brea s t c a nc er program at Duke Cancer I nst itute , in October 2015 was presented the Dist inguished Alumni Award, which is the Duke A lumni Associat ion’s highest honor. Blackwell is a 1989 graduate of Duke University.

A clinical oncologist at Duke since 1994, Blackwell has dedicated her time, research, and expertise to the mission of fighting breast cancer.

Over the pas t s evera l yea rs , Blackwell developed a new breast cancer treatment known as the “smar t bomb.” The t reatment , T-DM1, attacks a particular protein found in an aggressive type of late-stage breast cancer while leaving the healthy cells untouched.

Blackwell also played a major role in the development of another breast cancer drug, lapatinib.

Her research in the fight against cancer earned her a spot on TIME

Magazine’s “100 Most Influential People in the World” list in 2013.

Blackwell serves as professor of medicine and assistant professor of radiation oncology

at Duke University Medical Center and main-tains an active clinical practice. Her clinical and research interests surround the formation of blood vessels in breast cancer, breast cancer in younger women, and hormonal therapy.

Kimberly Blackwell

Kimberly Blackwell Wins Distinguished Alumni AwardNews

Blackwell dedicates her time, research, and expertise to the mission of fighting breast cancer.

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Supporters Receive Shingleton Award

D uke Cancer Institute (DCI) chose two foun-dations as recipients of the 2015 Shingleton

Award. Named for the institute’s visionary founder and emeritus director, the late William W. Shingleton, MD, the award recognizes people who have demonstrated exceptional service and generosity in furthering the institute’s mission to defeat cancer. The awardees are:

• The Rory David Deutsch Foundation • The Holt Brothers Foundation.

Ross and Mindy Deutsch lost their seven-year-old son, Rory, to a brain stem glioma. After his death, they established the Rory David Deutsch Foundation to eradicate pediatric brain tumors and other devastating childhood diseases as well as to make a difference in the lives of affected children and their families. They established the Rory David Deutsch Memorial Endowment Fund at Duke, and it has now become a $3 million professorship. They also provided support to help recruit Oren Becher, MD, as the first Rory David Deutsch Scholar. Becher studies central nervous system tumors in children and teenagers and new treatment regimens for children and young adults with gliomas. The couple have served on the Board of Advisors of the Preston Robert Tisch Brain Tumor Center at Duke since 2002.

Ellyn Samsky and Alan Samsky have been

instrumental in raising funds for the Rory David Deutsch Foundation. Ellyn is the sister of Ross Deutsch. The couple serve on the Board of Advisors of the Tisch Brain Tumor Center.

Terrence Holt and Torry Holt, both former standout football players for North Carolina State University and the National Football League, say they first learned the persistence and toughness they would need from their parents while growing up in Gibsonville, North Carolina. Their mother, Ojetta, the pillar of the family, was diagnosed with cancer when Torry was ten and Terrence was six. They lost their mother to the disease when they were teenagers. In 2000, the brothers realized their vision of providing education and empathy to children facing cancer in their families by founding the KidsCan! program, which now operates at four locations around the country. KidsCan! was launched at Duke in 2007 with donations from the Holt Brothers Foundation. The program, run by the Duke Cancer Patient Support Program, provides empathy, peer support, and education to children who have cancer in their family.

The awards were presented Oct. 29, 2015, at the Shingleton Awards Dinner.

The Duke Comprehensive Cancer Center (now the DCI) established the Shingleton Award in 1987.

Former NFL standouts Terrence and Torry Holt founded the KidsCan! program to give education and empathy to children facing cancer in their families.

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Mindy and Ross Deutsch (front row, far right) founded the Rory David Deutsch Foundation to honor their late son and to eradicate pediatric brain tumors. Relatives and supporters Ellyn and Alan Samsky (back row, third from left and far right), have been crucial in raising funds.

News

The Shingleton Award recognizes people who have demonstrated exceptional service and generosity in furthering Duke Cancer Institute’s mission to defeat cancer.

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d u ke c a n c e r i n s t i t u t e . o r g | DUKE CANCER INST ITUTE NOTES · 5

Surgeon Julie Ann Sosa, MD, professor of advanced oncologic and GI surgery, is an

international authority on thyroid cancer, and right about now her expertise is in great demand. Thyroid cancer is the fastest-increasing cancer in the United States in both men and women. In just three years, the endocrine surgery program that Sosa runs at Duke has grown from one surgeon to four.

But when Sosa started talking to environmental chemist Heather Stapleton, PhD, she started thinking about how to put herself out of business.

Stapleton, the Dan and Bunny Gabel Associate Professor of Environmental Ethics and Sustainable Environmental Management, runs the go-to lab in the nation for identifying flame-retardant chemicals lurking in furniture, TVs, and other products. Because chemical companies are allowed to keep their formulations secret, even furniture manufac-turers often don’t know which chemicals are in their products or how harmful they may be. Many flame retardants can slowly leach out of products and end up in the dust in your house. In almost all homes, Stapleton has detected traces of several chemicals that were banned years ago.

When Sosa met Stapleton through a colleague, she was fascinated to learn all of this. She was especially interested in Stapleton’s studies in animals showing that some flame retardants alter thyroid function, and that because of the shape of the molecules, the chemicals may be able to throw our

own hormones out of whack. Could the growing rate of thyroid cancer be

caused in part by exposure to these chemicals that are found in most of our homes?

Many scientists have thought about this question, but Sosa and Stapleton have the tools, knowledge,

and patients they need to actually explore it in real people. They’re doing just that in a pilot study, funded by Duke Cancer Institute’s pilot grant program in Cancer and the Environment.

Thyroid cancer incidence in the United States has increased more than 270 percent in the last 20 years. Rates are also increasing around the world. “It’s a pandemic,” Sosa says. Some have argued that rates aren’t really rising that much, but rather that more tumors are being diagnosed because of increased use of imaging, which detects even the smallest of tumors. “That isn’t the whole story, because it’s not just the smallest cancers that are increasing in incidence,” Sosa says. “And the increase is also being seen in developing countries; they’re not

doing more CT scans or more MRIs. There must be something else that could explain this.”

An environmental cause makes sense, especially since certain types of chemicals, known as bromi-nated flame retardants, can alter thyroid function.

“The chemical structure of one class of flame retardants is very similar to thyroid hormones that circulate in our body,” Stapleton says. “There are a number of different pathways by which these chem-icals can interfere with thyroid hormone regulation.

And we know that their use, and our exposure to these chemicals, has increased tremendously over the past several decades.”

Participants in Stapleton’s and Sosa’s study include Duke patients with thyroid cancer and people of the same age and sex who don’t have thyroid cancer. They provide blood and urine samples, and they allow Stapleton’s team to visit their homes to collect dust samples. The scientists extract the chemicals from the dust and blood samples and then identify them using a mass spectrometer.

In preliminary results, the team has found a connection between levels of one particular bromi-nated flame retardant and cases of thyroid cancer. People with higher levels of this chemical in their house dust are five times more likely to have thyroid cancer than others in the study.

Stapleton cautions that this result was found among a small number of people, so it isn’t yet statistically significant. She wants to recruit more participants to find out if the result holds up.

If this chemical or others are definitively linked to thyroid cancer, Stapleton would just as soon see them banned. “The chemicals in use now are just the chemicals that are currently available and cheap. But there are other chemicals out there that could potentially be used instead.”

In addition, Stapleton says that some manufac-turers may be using flame retardants even when they don’t need to. For example, her studies have found the chemicals in products that aren’t required to meet the flame retardant laws, such as nursing pillows and baby bath toys.

As a surgeon, Sosa’s focus is on removing thyroid cancer and doing it safely. But, more and more, she thinks about preventing the cancer, as well as the financial and emotional costs that go with it. “These are generally young and middle-aged patients who are given a diagnosis they will carry for the rest of their lives. They need surveillance, continued diagnostics, and treatment for decades,” Sosa says. “By operating, I’m helping one person at a time. But, together, I hope Heather and I can have a much bigger impact.”

This research is funded by a generous donation from Fred and Alice Stanback to Duke Cancer Institute and the Duke Nicholas School of the Environment.

Are Flame Retardant Chemicals Fueling Thyroid Cancer? by Angela Spivey

WANT TO PARTICIPATE?

The researchers are recruiting people diagnosed with thyroid cancer and people who don’t have thyroid cancer to participate in this study. To learn more, call Kate Hoffman, PhD, at 919-684-6952.

Doctors and scientists are studying whether exposure to common chemicals contribute to thyroid cancer risk. Duke Nicholas School of the Environment PhD student Stephanie Hammel and lab manager Amelia Lorenzo take dust samples from a home.

Lab manager Amelia Lorenzo, Heather Stapleton, and Julie Sosa in Stapleton’s lab.

Help us form more collaborations that can lead to prevention and cures: give online at gifts.duke.edu/dci or call 919-385-3129.

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notes

In Februa ry 2002 , Sabrina Lewandowski

o f R a l e i g h , N o r t hCarolina, had just hadsurgery to remove a braintumor—glioblastoma,one of the most aggres-sive. She was scared,and she didn’t knowanyone else living withthe disease. “When Iwas first diagnosed, Ihonestly thought I wasthe only one with a braintumor,” she says. “I feltso lonely.”

That changed in the spring of that year, when she attended her first Angels Among Us event. It’s an annual 5K run and family fun walk that raises money for research in the Preston Robert Tisch Brain Tumor Center at Duke. But for survivors like Lewandowski, the event is much more than that; it’s a lifeline.

“There were so many other patients there,” Lewandowski says. “When you meet a fellow survivor, you’re bonded. I felt good about not being alone.”

Every year since, Lewandowski has volunteered on the Angels planning committee. “My husband and I both wanted to give that wonderful feeling of the day to other people who come every year,” she says.

At the 2012 race, Lewandowski walked with her two-month-old daughter Layla. A nurse who had helped treat Lewandowski, Donna Van Arnold, brought her a baby blanket she had knitted. “It was so cold that year. That blanket saved us,” Lewandowski says. “I get to see these people one or two days every year. It’s almost like a family reunion. I can’t imagine not being a part of it.”

SONGS AND TEARS

Like Lewandowski, when Alan Stephenson of Bahama, North Carolina, first attended the event, he was recov-ering from brain tumor surgery. “That first walk, my wife Dianne had to hold my hand most of the way and help me keep my step,” he says. “But I wanted to get out and be around others who had

been through what I had.” That was in 2009. In 2010, Stephenson sang

“Angels Among Us,” a song made popular by

the country band Alabama. He sang with a group who traveled from Indiana to support another survivor, Eric Lacey. “Eric walked with us that year,” Stephenson says, his voice catching. “He used a cane and struggled around the course as many people do.” Lacey passed away before the next event.

The next year, Stephenson began performing the same song with Jeff Bradford, a brain tumor survivor who lives in Cary. Now it’s a tradition. “We’re surrounded on stage by survivors of all

ages,” Stephenson says. “It’s impossible for me to get through the song without crying. Maybe one of these days I’ll be able to do it.”

Bradford sees the Angels event as a celebration. “It’s a r em inde r t ha t we’re still here, still breathing,” he says. “It’s a tribute to all of those that weren’t as lucky as us to receive

the care that everyone gets at the Duke brain tumor center. They give you the best chance you have anywhere. They give 125 percent.”

Both men raise money for the event. Bradford and his wife Andrea and daughters Zoe, Riley, and Ella Grace make bumper stickers and magnets

to sell. In 2015, Stephenson and friends hosted a rock concert and split the proceeds between Angels Among Us and Sam’s Wish Fund, a charity that grants wishes to sick children. “Many of the treatment breakthroughs at Duke happen as a direct result of Angels Among Us and what these teams raise—whether it’s a team of 5 people or 200,” Stephenson says.

LIKE CHRISTMAS

Chesley and Van Gresham of Greensboro, North Carolina, look forward to Angels Among Us in the same way that some families anticipate Christmas. “Family members come from northern Virginia, and if they don’t get to come, they’re upset,” Chesley says. “Everyone can’t wait to mark it on their calendars each year.” In 2015, 30 people

from their family attended.

The Greshams began supporting the event in 2006, the year af ter their son Tate had surgery at Duke to remove a brain tumor. He was just two years old. Now age 11, Tate ran in the Angels5K in 2015. “Hewas all riled up that his time beat some of the adults,” Chesley says. “He is doing fantastic—smart, sweet as can be, and a really good kid.”

“Team Tate” raises funds for Angels through an annual pig picking, which they hold during a foot-ball tailgate at Virginia Tech, Van and Chesley’s alma mater. “We felt that Duke saved Tate’s life. We want to help them do the same for others,” Chesley says.

The 23rd annual Angels Among Us 5K and Family Fun Walk is Saturday, April 23, 2016. Register or learn more at angelsamongus.org.

22 Years of Celebrating Life Brain tumor survivors say the annual Angels Among Us fundraising event feels like a family reunion. by Angela Spivey

Thirteen-year brain tumor survivor Sabrina Lewandowski now shares Angels Among Us with her daughter Layla.

Find out how you can give hope to people with brain cancer: visit angelsamongus.org.

ANGELS AMONG US BY THE NUMBERS

In 1994 (the 1st year the event was held), 200 participants raised $27,000.

In 2015 (the 22nd year the event was held), 4,000 participants raised more than $2 million.

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Survivors Alan Stephenson and Jeff Bradford sing the “Angels Among Us” song at the event each year.

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d u ke c a n c e r i n s t i t u t e . o r g | DUKE CANCER INST ITUTE NOTES · 7

WHAT DO YOU MEAN BY “FINANCIAL TOXIC-ITY,” AND WHY IS IT IMPORTANT?

Financial toxicity is a term we coined in the literature to describe how cost of care for

cancer patients impacts their wellbeing, quality of life, and quality of care. Different people experi-ence it in different ways; it can be anything from paying $50 out of pocket a month more than you expected, all the way to declaring personal bank-ruptcy as a result of cancer treatment, or anything in between. It’s any unexpected cost as a result of cancer care that impacts patients’ wellbeing.

WHAT CAN FINANCIAL TOXICITY LEAD TO?

The biggest direct consequence is that financial toxicity can impact whether patients stay on their treatment. When patients struggle to pay for treat-ment, in many cases they stop it. They’re likely to give up potentially life-saving treatment because of that potential cost.

There was an interesting study that found that a diagnosis of cancer more than doubles a patient’s risk of declaring personal bankruptcy. That risk holds true regardless of the type of drugs or the type of cancer; just the diagnosis produces this result. Those same investigators found that, for those patients who do declare bankruptcy, there is a 70 percent greater risk of mortality. It doesn’t just hurt your finances; it hurts your outcomes.

WHAT CAN PHYSICIANS DO TO HELP PATIENTS DEAL WITH THIS PROBLEM?

When we prescribe a treatment for patients, we counsel them on potential physical toxicities. We need to do the same thing with potential financial toxicity. We need to say, “Even though you have insurance, you might get hit with a bill for this.”

So much of the cost of medical care is unknown up front. You would never walk into a car dealer-ship and say, “OK, I’ll take that one. Just bill me later.” But we’ve been trained to do that with health care, because traditionally insurance paid for most procedures. But now more of those costs

are being borne by patients; not only is the cost of treatment going up, but so is the percentage of costs that insurers pass on to patients. We should make sure our patients understand that.

In cancer care, for example, I know that oral chemotherapy can often include very high out-of-pocket costs for patients. So before I send a patient home with an expensive prescription, I’ll ask our pharmacist to run it through their insurance plan, so the patient knows before they leave how much their copay will be, and whether they can afford it.

Just as we draw on various disciplines to address patients’ physical problems, we need to draw on various disciplines, like pharmacists

and social workers, to address their financial ones. I think a lot of physicians don’t want to bring up costs because we don’t know the answers. But there are people around us who do know the answers. We need to bring them into the discussion up front.

WHAT CAN PATIENTS DO TO MANAGE THE FINANCIAL EFFECTS OF CANCER CARE?

The first thing is awareness. It’s important to realize that even if you have insurance, you may get hit with big bills.

The second is engagement. Don’t be afraid to bring up cost. Don’t be afraid to ask your doctor how much a particular drug is going to cost, and if your doctor doesn’t know, ask them who does. That can prompt the doctor to pull in other people on the team.

Some resources are available. Pharmaceutical companies have patient assistance programs. Charitable foundations can help with expenses. So there are some resources out there, but for the most part, I don’t think many patients are getting to these in a timely fashion.

In my research, we’re developing a web-based app where patients can enter their diagnosis and treatment, and we give them education on where to find potential resources. We teach them how to talk to their doctor about the costs of care and how to overcome the barriers to having that conversa-tion. It’s in pilot testing right now.

WHAT DO YOU HOPE TO SEE HAPPEN IN THIS AREA IN THE COMING YEARS?

Major changes will have to happen in the policy realm. Value-based insurance design, for example, basically helps decrease out-of-pocket payments when cost is going to potentially impact whether a patient can get treatment. There are things like accountable care organizations and bundled payments, where they say, “For this diagnosis you get X amount of money. You can do whatever you want as long as it falls within that amount.”

I hope we see some real policy changes. Maybe we start letting the federal government actually negotiate prices with drug companies. That’s part of the drug approval process in Europe. But here, by law, we’re not allowed to think about cost when we approve a drug in the U.S.

The point is that more people than we realize are suffering as a result of the financial burden of their health care, including cancer care. According to the U.S. Centers for Disease Control, one out of three Americans has trouble paying their medical bills. So this is a very prevalent problem. It’s not just a few people who have inadequate insurance or no insurance.

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Yousuf Zafar, MD, associate professor of medicine, is a medical oncologist and health sciences researcher at Duke Cancer Institute and the Duke Clinical Research Institute who focuses on improving care delivery for patients with advanced cancer.

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Seeking the Antidote for Financial Toxicity

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Yousuf Zafar