The estimated population of cancer survivors will increase to 20.3 million, almost 10 million males and 10.3 million females, who will still be alive by Jan. 1, 2026, according to the American Cancer Society.
A large part of the increase of survivors is to advancements in cancer research, treatments and procedures that are allowing tumors to shrink, cancer cells to die and the disease to go into remission. Even those with life-limiting illnesses to prolong and improve their quality of life.
Locally, the Goldschmidt Cancer Center, which is part of Capital Region Medical Center, JCMG Oncology-Hematology and SSM Health Cancer Center at JCMG all have seen advancements in treatments, procedures and testing that can help further personalize each patient’s cancer care.
Having a multidisciplinary approach to any cancer treatment, including breast cancer, is a No. 1 priority for most medical staff.
“Studies have shown that a multidisciplinary approach to the treatment of breast cancer is not only necessary but can greatly improve the overall treatment course by integrating surgery, radiation and chemotherapy opinions into a carefully crafted individualized plan of treatment for each patient,” said Dr. Jay Allen, M.D., radiation oncologist at Goldschmidt Cancer Center and native Missourian who has practiced for about 20 years with the same group of radiation oncologists. “This takes into account not only their stage and type of cancer but also their overall health, and in some cases social situation and ability to access healthcare.”
One of the latest achievements in breast cancer treatment represents a cooperative effort between the surgical service and radiation therapy for scheduling and delivery – Intra-Operative Radiation Therapy (IORT). Goldschmidt Cancer Center, which is part of Capital Region Medical Center, is currently the only center in Missouri to offer this option to patients.
Allen said breast cancer patients who choose lumpectomy surgery for breast conservation have been a group particularly well suited for radiation therapy in the operating room. IORT is a technique that allows for delivery of a single large dose of radiation to the operative bed (lumpectomy cavity) immediately after removal of the tumor while the patient is still under general anesthetic.
“During the procedure the surgeon identifies the first lymph node to drain the tumor site through a procedure known as sentinel lymph node biopsy. This lymph node is then sent to the pathologist for a preliminary verification that there are no cancer cells hiding in the lymph node,” he explained. “The surgeon then follows with localized removal of the mass with a margin of normal tissue surrounding it. … Surgical margins are then evaluated clinically.”
After a preliminary evaluation of margins and sentinel lymph nodes are both found to be negative, a treatment balloon is placed in the operative cavity and filled with a sterile saline solution, placed inside the cavity and temporarily closed, Allen said.
“A small X-ray tube on the end of a wand is then placed inside the balloon through a catheter and the dose of radiation is delivered to a precise location encompassing the edges of the surgical area,” he explained, noting a radiation oncologist like himself administers it. “This is done to neutralize any microscopic cancer cells that may be left behind at the time of surgery. In doing this the risk of the cancer coming back in that particular area is significantly reduced. … Once complete the balloon is removed and the surgeon closes the operative wound.”
Early stage breast cancer patients are considered some of the best candidates for safe delivery of radiation during surgery for many reasons, Allen said. First, the breast is outside of the body cavity and not surrounded by other internal organs.
“This means that the intra-operative radiation delivery is less likely to impact important organs nearby that don’t need treatment such as the lungs and the heart,” he added.
The tumor also has to be less than or equal to 2 centimeters and no lymph node involvement, which limits the pool of candidates to those most likely to have microscopic cancer cells no more than 1 centimeter past the edge of the cavity.
“For example if a lymph node is positive then cancer cells have already traveled to the under arm area and would be outside the reach of the highly localized treatment and the patient would not be a candidate. We have external beam X-ray treatments available for those patients,” Allen said, noting patients are also required to have positive estrogen and progesterone receptors and negative Her-2-neu protein expression. “There is also an age criteria and patients need to be 60 years of age or older.
This group of breast cancer patients generally have a lower lifetime risk of local recurrence and are considered excellent candidates for minimal treatments.”
Allen said in the past, the radiation treatment was only done at a few large research centers and each center had made its own equipment.
Over the past few years, equipment and treatment delivery have been standardized and the technology has improved. “Our team traveled to Chicago Rush Medical Center and reviewed the actual treatment delivery with their team of experts. We put together a program for CRMC with the surgeons and operative personnel and have now had three initial candidates and two of them have gone on to receive the treatment. The third one was found to have a positive lymph node and did not qualify as a result,” he said. “The patients are very pleased with the outcome and the fact that they don’t have to come back for multiple treatment visits.”
Additional benefits to IORT include less travel time to the treatment center, shorter healing time, fewer skin side effects and surgery and radiation are complete when the patient wakes up from anesthesia.
Like with the IORT, the mission and vision for Goldschmidt Cancer Center and Capital Region Medical Center staff is to put patients’ needs and concerns front and center, committed to recommending and delivering the most appropriate treatment plan for each individual patient according to National Standards of Excellence. As a result, they provide each patient with a personalized plan that includes the best treatment available for his or her particular cancer and delivered in a timely manner with the fewest side effects possible, Allen said.
“The unique ability to deliver IORT revolves around the willingness of the physicians to coordinate scheduling and planning so that patients may take advantage of this treatment,” he said.
The center also offers equipment with a full complement of capabilities including Stereotactic Body Radiation Therapy (SBRT), which allows reduced treatment visits for a number of different cancers including lung, bone, central nervous system and come abdominopelvic cancers. Patients can also enroll in numerous clinical trials through NCI designated cooperative trials with access to nationwide clinical trials locally, receive numerous avenues of assistance to help with expenses, nutritional supplementation, travel and psychological issues, and enroll in a cancer wellness program to get healthier once they have completed treatments.
For more information, contact Goldschmidt Cancer Center, located at 1432 Southwest Blvd., at 573-632-4800 or visit crmc.org/services/cancercare.
The transitions of cancer therapies over the years started with a few available chemo treatments.
“Oncologists were like chefs, doing their mix and hoping for the best,” said oncologist Dr. Shadi Haddadin, M.D., at JCMG Oncology-Hematology. “However, with time and better drugs becoming available, better control of treating the drugs’ side effects and treatments were conducted in a cancer clinic instead of spending weeks in a hospital.”
In the last 10 years, personalized medicine has been a primary focus, with studies and research showing that each cancer is different and so is each patient’s response to the disease and treatments. Within the last couple of years, oncologists have looked at cancer in a different way, and at JCMG Oncology, Dr. Haddadin has utilized important testing options and treatments to personalize cancer care to each patient.
Genomic testing is one option that can open the door for a variety of ways to help fight different types of cancer. Haddadin said a sample of the cancer is sent to a specialized lab where the sequence of the genome, or genetic material, is tested.
“Typically what we are looking for is certain alterations in the chromosomes; we call them mutations. These mutations tend to be the drivers behind the cancer in some of these cases,” Haddadin said. A second way to test for available drugs that can target specific mutations or alterations is to test a patient’s blood, in which cancer cells often shed their DNA. “Some of these mutations can be blocked or inhibited by available drugs.”
For example, a patient that has stage 4 lung cancer should undergo genomic testing, Haddadin said. EGFR, or epidermal growth factor receptor, is a protein on the surface of cells that helps them grow and divide. At a progressive state of lung cancer, those cells have too many, which makes them grow faster, according to the American Cancer Society. Drugs are now available that are EGFR inhibitors and block the signal from the EGFR, which tells the cell to grow.
“I have an elderly patient with stage 4 cancer and she is not a good candidate for chemotherapy. She had the EGFR mutation and was lucky to have that mutation. She has taken these pills for more than a year and is doing everything she did before with minimal side effects,” Haddadin said. “She is a perfect example of successfully using these oncology advancements that help her maintain her lifestyle.”
Patients that have advanced stages of the disease benefit most from these options. They often have failed the first or second lines of treatments or have a rare cancer where genomic testing and subsequent target therapy drugs can help fight back.
“In time, this will be more refined. It will be every patient that comes in will be tested and at least this will be the standard of care in the future,” Haddadin said. “You are a patient, you are unique, and you have a cancer that is unique. If we know the driver behind it, we can at least give you a drug that blocks that cancer, and we have great responses.”
Haddadin said the list of medications is growing and helps fit those patients with a variety of advanced cancers. Another type of genomic test, Oncotype DX, helps analyze the activity of a group of genes that can affect how a cancer is likely to behave and respond to treatment, according to Breastcancer.org. It helps doctors determine a woman’s risk of early stage, estrogen-receptor-positive breast cancer reoccurring and benefits of chemo and radiation treatment.
“It’s like trying to cross a river and you don’t know how to swim and don’t have a boat; you will not be able to do that. Within the DNA of these cancer cells, we can look for genes that allow them to have the tools to spread,” Haddadin said. “This is a test we run and will give us three risk groups the patient could fall into. In the high risk group, the chances the cancer will spread are very high and we give them chemotherapy. The low risk group tells us there is no benefit to giving them chemo. For years, we were stuck with the group in the middle.”
In June, a recently published study was shared with Haddadin and fellow oncologists at a gathering in Chicago that stated patients in the immediate stage often did not need chemo for early stage breast cancer. Instead, they should use hormone therapy, Haddadin said.
“Now, we have less and less patients needing chemo for early stage breast cancer because of this test and this study,” he said.
Immunotherapy is another advancement leading the oncology world. The function of the immune system is to fight anything that comes in from the outside, as well as cleaning up any internal threats, like cancer.
“The cancer cells can sometimes be smart. They find a way to disguise themselves or find a way to block the immune system,” Haddadin said. “For many years, they have tried to find ways to boost the immune system to find cancer cells and hopefully avoid going through chemo and things like that.”
Haddadin said some people look at alternative medicines, many of which are not approved by the FDA. However, in the past five to 10 years, a new family of drugs were started, including PD1 inhibitors that block the ways cancer cells disguise themselves and expose them to the immune system.
“They also activate the immune system to fight the cancer. One of the first cancers we studied immunotherapy in was melanoma. In the past few years, we went from one cancer to (about nine or 10),” he said. “Every month, we get a new indication.”
For example, a new immunotherapy drug Haddadin has used for the last year at JCMG Oncology uses the Herpes virus and is injected into melanoma lesions, breaking down the cancer and also affecting other spots around that area. One of Haddadin’s patients took this drug every two weeks for six months and the lesions had shrunk considerably.
JCMG Oncology-Hematology provides more specialized and multidisciplinary cancer treatments, also working with a multidisciplinary team including a surgical specialist, radiation oncologist, radiologists, pathologists, experienced compassionate nurses and occupational therapists, at its core.
With cancer support groups, dietitians and psychologists available for those diagnosed with cancer, JCMG can offer a wide spectrum of services. Haddadin is appreciative of the advancements made in oncology and knows more are to come.
“There are so many cancers, but you have something new coming out every day for each one,” Haddadin said. “Over the coming years, we will see immunotherapy being used in almost every cancer. It works and is better tolerated. What better to fight your cancer than your own immune system… These are things our patients can get locally at JCMG Oncology.”
For more information about JCMG Oncology-Hematology, 1241 W. Stadium Blvd., call 573-556-7718 or visit www.jcmg.org.
Even though radiation therapy has been available for some time, advancements in types of radiation therapy have allowed more patients to receive specialized treatments that provide better benefits.
“With the advancements in technology and medicine, more cancer patients qualify for specialty treatments,” said Kim Menefee, manager at SSM Health Mid-Missouri Regional Cancer Center. “This cuts down on active, more traditional treatments and can often be more effective with a better outcome for certain patients.”
Since SSM Cancer Center at JCMG opened in April 2014, they have offered a series of specialty radiation therapy procedures utilizing its top-of-the-line linear particle accelerator, which delivers high-energy X-rays or electrons externally to the region of the patient’s tumors and works to damage DNA of the targeted cancer cells.
Menefee said within the last eight months to a year they have seen their patient population transitioning from traditional radiation treatments, which are often scheduled five days a week for five to six weeks, to more specialized treatments and procedures, with roughly 50-60 percent qualifying and using the latter.
One such specialty treatment is considered a surgical procedure, Stereotactic Radiosurgery (SRS). The procedure uses many precisely focused radiation beams to treat tumors and others and like other forms of radiation damages the DNA of the targeted cells, forcing disability of the cells to reproduce and tumors to reduce.
“Since this is a targeted form of radiation, it is considered a form of surgery. It is noninvasive, with no scalpel involved and nothing done internally to remove anything,” Menefee said. “It is so precise and concise, it only needs to be done one time. … This is often used for brain tumors, or cancer that has metastasized to their brain.”
Another procedure that is more advanced that the traditional external beam radiation therapy is Stereotactic Body Radiation Therapy (SBRT). This therapy uses special equipment to position a patient and precisely deliver radiation to tumors in the body (except the brain), according to the National Cancer Institute. The total dose of radiation is divided into smaller doses given over several days and spares normal tissue.
“They may have to come to five to seven treatments instead of a traditional course of 36 treatments,” Menefee said. “It helps the tissue that is affected. It delivers targeted efforts of radiation on the tumor and spares the surrounding areas. A lot of lung cancer patients use SBRT.”
Using a separate modality and piece of equipment, High Dose Rate (HDR) brachytherapy is a specialty treatment used primarily for those with breast cancer.
“Even though it has the ability to treat other cancers, 95 percent are breast cancer patients,” Menefee added. “Different from the linear accelerator, NDR houses a form of internal radiation inside the machine and catheters are temporarily placed into a cavity where cancer was. Radiation is delivered into the tumor inside the body.”
Menefee said the patients will use HDR brachytherapy twice daily for one week.
“The radiation is delivered very specifically to the tumor bed and cavity created,” she said. “It spares tissue and encourages faster healing time. It also increases opportunity for curative treatments.”
Menefee said many patients qualify for specialty treatment, but many others don’t need it, either utilizing traditional external beam therapy or none at all.
“Sometimes after a cancer patient has a lumpectomy, they are tested and it is determined HDR is not for them. They still need radiation therapy,” she said. “There is still going to be benefits from that method of delivery, as well.”
Specialty radiation therapies can also help with palliative care, which a medical care approach for people with life-limiting illnesses. These treatments can help them receive some relief, pain and ease to have a better quality of life.
“It can be helpful for patients that are well aware their cancer diagnosis is not going to be curative, preserving their quality of life and allowing them to accomplish the things they want to do,” Menefee said. “Specialty treatments allow them to do so with noninvasive, relatively quick treatments that do not tie them up all day, have few side effects and are precise.”
At SSM Health Cancer Center at JCMG, the medical staff tries to treat about any cancer they can.
“If it is beyond our ability in terms of technology, we have people waiting down the road for our patients,” Menefee said. “For fou-plus years, our cancer center has been about these patients. Our physicians, our therapists, our staff, you name it – we are there for patients. Those people are the internal drive for cancer care. They are going to help each patient with compassion and in providing the best personalized care we can.”
For more information about SSM Health Cancer Center at JCMG, located at 1241 W. Stadium Blvd., call 573-635-2282 or visit cancercarejc.com.