Archive for August, 2012

 

Aug 26 2012

A Sound Strategic Foundation

by at 11:16 pm

This is my last blog until after Labor Day. Harriet and I are heading off for a week in New England, and are looking forward to winding up the summer with this short trip. We’ll be up in the Berkshires for a few days of the trip, and will have to bring some sweatshirts to deal with the evening chill. It seems like forever since we have had to think about bundling up…

Last week was a bit quiet for meetings because many people are out of town. But there was still a lot of work to do. A highlight were two wonderful and very productive strategic planning sessions held  Monday and part of Tuesday to better define Lombardi’s vision, mission and objectives. A group of about 15 Lombardi leaders participated in this exercise, with the very able facilitation of a professional consultant, Alan Spector.

While a sound strategic plan is the foundation for a strong CCSG submission, we quickly saw how this process can help focus our efforts in many ways that extend well beyond the CCSG. We have more work to do, and more people to bring into the process, but for now I can share the vision statement we devised: to prevent and cure cancer with a local focus and global impact.  This is intentionally broad; the mission statement is what helps describe our unique contributions to this overarching vision.

We hope to continue the process of fleshing out the plan over the next few months.

Another highlight for me was the Hyundai Hope on Wheels event last Wednesday. Through this excellent program, Hyundai has given Lombardi’s pediatric program nearly $500,000 over the past nine years. Hyundai awarded $75,000 to Scott Myers this year for his important work in the long-term effects of cancer treatment in children. 13-year-old Zoe Chen, who was diagnosed with acute lymphoblastic leukemia two years ago and recently completed her treatment, delivered some inspiring remarks and words of advise for other young cancer patients.

See you in September!

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Aug 19 2012

Food for Thought from a Busy Clinic Afternoon

by at 7:16 pm

As I write this blog on a lazy Sunday afternoon a monsoon is raging outside, so outdoor activities will be somewhat limited today. But it is nice to take a break after a busy week.

We had two bittersweet goodbyes last week. Mia Caparas is leaving the area to pursue a Pharm.D. Degree at Fairleigh Dickinson University in New Jersey. Thanks, Mia, for all you have done. And, Dr. Andrew Putnam is leaving MGUH for Yale University. “Put’ has been the face of palliative care for Lombardi’s patients for some time, and we will miss him. I wish him well in his new endeavors.

My Thursday afternoon clinic was quite busy, with three new patients, and a number of follow-up patients as well. One of the new patients has metastatic pancreatic cancer that progressed when he was treated with gemcitabine, which has been the single-agent standard of care since it was approved in 1996 based upon a less than 10% objective response rate, a minor improvement of quality of life and average survival of six months. When his disease worsened his oncologist added the oral agent capecitabine, a fluoropyrimidine with nearly no single-agent activity in this disease, and no documented utility  in combination with gemcitabine in this clinical setting. I don’t blame the oncologist, who was merely trying to help his patient, but this vignette neatly capsulizes one of the major challenges we face in the field of health care.

How can we possibly afford to take care of people when they are able to receive expensive, largely ineffective therapies? And, how can we make progress when more than 95% of all cancer patients receive all their treatments outside the context of clinical trials that can identify newer, better treatment approaches? Surely, there must be a better way.

I do not believe the answer lies in restrictive rationing. This approach flies against the unspoken contract that doctors have with patients in our society – that we will do what is best for the individual patient – essentially, that people matter. The potential violation of this “contract” by certain elements of recent health care reform efforts struck a chord with many Americans, and created ideological polarization that precludes respectful and thoughtful dialogue. Sadly, this has interfered with the obvious opportunities we have to do what is right for each individual by practicing true evidence-based medicine. For example, there is no evidence that any so-called second-line therapy composed entirely of currently standard agents has utility in metastatic pancreatic cancer. However, this is a great opportunity to test new agents and therapeutic concepts in clinical trials that might actually make a difference in the lives of these patients and those who will follow.

In a very real way, this approach puts the patient first by sparing the toxicity, inconvenience, wasted hopes and expense of therapies that are doomed to fail. Since the incremental cost of conducting such trials is typically borne by pharmaceutical company sponsors that will benefit from approval of their drugs, the cost of care to the public is reduced, and conditions for innovation and progress are incentivized. Now, imagine the impact if these principles were applied to other cancers, and indeed to other diseases.

Much of what we do is well intentioned but misguided. If we just put the patient first, and do so with a clear-eyed understanding of how effective our interventions are likely to be, we can reduce the cost of care and accelerate progress. This is but one element of a much larger and complex puzzle, and this is just my personal opinion. The Medical Center is putting together a working group to examine this and many other questions related to the important issue of health care reform — what an interesting discussion that will be.

Meanwhile, I plan to do my part by screening this patient for participation in clinical trials for which he might be eligible. I will let you know how it turns out.

My coming week will be highlighted by a Strategic Planning exercise that will involve many of Lombardi’s leaders, and by preparations for our September 11 External Advisory Committee meeting. I hope you have a good week, even if you are not on vacation!

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Aug 12 2012

Celebrating Promising Trainees

by at 10:09 pm

The summer is flying by, even though it has not cooled off very much. Speaking of things flying by; I got back my car on Friday, following a nearly three-week stay at an auto collision shop to recover from the destructive effects of a thunderstorm-driven dead branch in Parking Lot E. All is well that ends well, but  the collision shop owners must be the happiest folks in Virginia. Things certainly worked out well for them!

This past week was punctuated by CCSG-related meetings, and a very productive meeting with Andrew Pecora from Hackensack University Medical Center to discuss our evolving collaboration, with an initial emphasis on bone marrow transplantation.

My Wednesday morning was highlighted by a photo op in the clinic with John Deeken and Brandon Smaglo, one of our fellows. The GUMC website will be highlighting Brandon’s recent participation in the ASCO/AACR Clinical Methods Workshop in Vail, CO last month. Brandon has written a clinical trial combining an ABL inhibitor with cetuximab, an EGFR inhibitor, based on work done by John Deeken and by my lab as well. The workshop is the world’s best opportunity for promising trainees or junior faculty members to gain experience in clinical trials methodology. It is intensely competitive, and Brandon wrote a compelling application, and certainly made the best possible use of the experience. I spent 10 years as a faculty member, and three of them as one of the course directors. While I don’t miss the hardest working week of the year, I do miss the inspiring interactions afforded by the opportunity. I never failed to learn something new and important from every lecture, workshop and group session in which I participated. Brandon will not only benefit from having had to assimilate an astonishing amount of new information delivered through the firehose that is Vail, but he will have a new sense of what is possible in his life, and has met over 100 new colleagues whose paths will cross his for the rest of his career. How cool is that?

I spent all day Thursday up at the NCI performing a portfolio review of the NCI drug discovery and drug development programs as a member of the NExT panel. I am happy to report that I had to recuse myself from two discussions because they involved Lombardi members. It’s nice to know that we are very much in the mix in this important area.

And, on Friday, Harriet and I drove up to Philadelphia in a driving rainstorm (think “monsoon”) to attend the White Coat ceremony of our daughter-in-law, Sarah, who is married to our oldest child, Ken. Sarah starts her first year of medical school at Drexel University College of Medicine on Monday; it was wonderful to celebrate this accomplishment with her and to wish her well on her journey. We celebrated that evening at a terrific Indian Restaurant (Tashan) in South Philadelphia that reminded us of Rasika here in DC. After breakfast on Saturday we headed back down I-95 to prepare for our last party (held Sunday evening) to welcome Mike Atkins and his wife, Susan Crockin, to Lombardi. Mike has already very much become a member of the Lombardi family, but who can argue with having a party?

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Aug 05 2012

A Massive CCSG Push

by at 6:32 pm

Sorry I missed  my blog last week, but we were up in Philly last weekend and I just didn’t get my writing hat adjusted in time. Well, it’s summertime, so I guess I am allowed a week off from the blog.

However, that break does not extend to preparations for the CCSG competitive renewal. I believe I have read preliminary drafts of every program, all of the shared resources, and virtually all of the administrative sections. And, I have been working hard to incorporate that information into my overview and description ofthe cancer center’s essential characteristics. I have not been alone — Carolyn Hurley, Mike Atkins and Steve Byers have read every word too, aided by so many people, with special thanks to Ellen McLaughlin and Michael Vander Hoek. We have met with the program leaders, the Shared Resource directors and all of the administrative leads to review their drafts and pepper them with suggestions and edits. We are getting ready to send out these cleaned up first drafts to our External Advisory Committee on August 10, so the members have a chance to review their assigned portions in advance of the EAC meeting on September 11. We are on target, and look forward to getting the EAC’s feedback to help us polish the drafts by the end of the calendar year. This will give us time to weave together the stories we have to tell. There are many of them, they are really very good, and they accurately portray the many dimensions of Lombardi’s excellence.

A special word about Carolyn Hurley; she has done an utterly remarkable job of mobilizing this incredibly complex effort. Not only will the CCSG be in great shape in time for the May submission, but we will be a much better cancer center as a result of her efforts.

While my past two weeks have been partially consumed by CCSG reading, writing and meetings, I have continued to see patients. You will no doubt remember my young patient with metastatic colon cancer from my prior blogs. He resumed chemotherapy two weeks ago with 5-fluorouracil, oxaliplatin and bevacizumab. He is tolerating chemotherapy well, and had a routine restaging CT scan last week. Not surprisingly, the CT scan shows worseningof the liver metastases as he has been off chemotherapy for two months while he prepared for and recovered from his colon surgery. Needless to say, he was quite concerned, and we spent some time on the phone discussing his situation. I do hope that the addition of  bevacizumab will increase the sensitivity of his cancer cells to the chemotherapy agents. There is good reason to believe this can happen based upon a large amount of clinical literature. I will let you know if my hopes are rewarded with good results when he has his next CT scan in about two months.

Interestingly, our many CCSG-related meetings reminded me of all the remarkable talent we have on this campus to address the role of anti-angiogenic agents like bevacizumab in cancer therapy. On Thursday, we reviewed the ET program’s draft overview. John Marshall, who has been a prime implementer of bevacizumab-based therapy in colorectal cancer, was part of this discussion. So was Anton Wellstein, an angiogenesis expert witha longstanding collaboration with Chris Wilcox to study the interaction of angiogenesis and blood pressure control. They were joined by Mike Atkins,who has published extensively in this area and is in the process of designing a clinical trial that will examine the role of hypertension as a biomarker of angiogenesis inhibitor efficacy. With such firepower, and my own interest in monoclonal antibodies, it sounds like we have an opportunity to extend this research area. My patient certainly needs all the help he can get.

I hope you’ve stayed cool this weekend. I was happy to attend the wedding of the daughter of old friends, and to letting my eyes uncross and my brain recover a bit from my serious case of CCSG-itis.

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