Teamwork by the Dozens
Opposite page (first row, left to right): Nurse Martha Ryan, survivor and volunteer Col. Jim Stapleton, Jonathan Beitler, radiation oncologist. (Second row) Speech pathologist Meryl Kaufman, physicians William Grist, Dong Moon Shin, and Amy Chen.Winship's head and neck cancer program defines multi-disciplinary care, and patients win from the teamwork—and hard work.
By Lynne Anderson / Photography by Jack Kearse
Scott Brennan Atlanta VAMC
Tiffany Barrett, MS, RD, LD, clinical dietitian
Kristin Burson, certified tumor registrar
Carol Rivera, BSW, social worker
Sarah Zingarelli, library specialist, neuroradiology
The sun shows no signs of rising on this rainy February morning, and the streets are nearly bare. A drive down Clifton Road from the CDC to Winship takes two minutes flat, even after a red light or two snags you. Buses and shuttles are rare, and valet parking hasn't opened.
So it's a little surprising to walk into the boardroom on the fifth floor of Winship Cancer Institute to find a hive of activity and conversation.
About 50 doctors, nurses, and other members of Winship's head and neck cancer team are wide awake and in full work mode, long before they will dash off to their clinics, operating rooms, labs, and offices to begin a full day's work there.
It's the head and neck program's tumor board meeting, and it happens every Tuesday at 6:30 a.m. This team of experts comes from surgery, radiation and medical oncology, pathology, radiology, nutrition, nursing, social work and speech pathology. They will discuss every head and neck cancer patient seen in the past week before they leave.
While it may not be enough to rouse the average person out of bed at 5 a.m., those in attendance wouldn't want to miss it. They know their collaboration makes a difference in their patients' lives and that it helps improve treatment.
"We present every single patient —including those seen at Emory Midtown and the VA Medical Center —to make the best decision for patient care," says Dong Moon Shin, associate director of Winship and director of the head and neck cancer program at Winship. Even patients whose cancer may not appear to be life-threatening can have "major complications, major issues," that physicians bring to the tumor board to discuss, explains Shin, a medical oncologist.
And this is not just any tumor board—it's a working board of more than four dozen experts.
"There's a lot of experience in that room," says Jonathan Beitler, a radiation oncologist who specializes in head and neck cancers. "It's a good way to see the same evidence at the same time. There are decades of surgical experience in the room. It's a great way to provide patients the very best care."
Preparation and organization are key, says Nabil Saba, a medical oncologist who specializes in head and neck cancers. "It's become an example of what a multi-disciplinary care program can be."
Other tumor boards meet at Winship, and they all have patient care as the primary focus. The head and neck tumor board meeting may be one of the best examples, however, of the interdisciplinary work that sets Winship apart—and helps ensure that patients receive the benefit of expertise from several disciplines.
Collaboration is becoming more and more key in unlocking cancer's dark secrets. Winship is known for collaboration across disciplines and within departments; Winship's deputy director, Fadlo R. Khuri, has said that a willingness to collaborate is a job requirement.
"The thing that we always remember is that we are here for the patients, not for ourselves," says Khuri. "The head and neck cancer team is an outstanding example of brilliant scientists and clinicians coming together toward one common goal—helping our patients get well, with minimal side effects."
It's easy to see what Khuri is talking about when trying to interview and photograph members of the head and neck cancer team. Shin doesn't want to leave anyone out and recites from memory the entire team and each of their responsibilities, excitedly talking about each one. When it's time for a photo shoot, he wants to try to get everyone in the picture.
"This is one of the largest interdisciplinary tumor boards anywhere in the nation," explains Shin. "Patients are receiving the best of care from the best of the experts. And that care is enhanced because we have so many committed members of the treatment team who come together with great knowledge and great compassion to make sure our patients are getting the best care possible."
Winship's head and neck cancer program stands out not only because of exceptional patient care but also because it is one of only five in the country to be designated a Head and Neck Cancer Specialized Program of Research Excellence, or SPORE. "We are very proud to have established such a prestigious program at Winship, and it's also the only SPORE in the state of Georgia," says Shin. SPORE grants are funded by the National Cancer Institute and bring with them about $2.5 million in research funding each year for five years. The research program is very comprehensive, consisting of four major programs, research shared resources, a career development program, and a developmental research program.
In a state and region where head and neck cancer rates are higher than the national average, the head and neck cancer program is a critical piece of Winship's efforts.
Collaborative care for a tough disease
"There's evidence that shows that aggressive, supportive care improves outcomes. Instead of everyone going up for a pop fly, thinking someone else has it and the ball gets dropped, here, the ball doesn't get dropped." — otolaryngologist Amy Chen.
Head and neck cancers include cancers of the mouth, lips, nasal cavity, sinuses, throat, tongue, salivary glands, and larynx. Risk factors include cigarette smoke and alcohol use, but many patients have never smoked or used alcohol. Winship treats about 750 newly diagnosed patients a year with the disease.
In recent years, the number of patients diagnosed with head and neck cancer had been falling. That was due, in some measure, to a decline in tobacco use. Now, a recent spike in certain types of head and neck cancers has been associated with the human papilloma virus-16, or HPV16. Many experts believe such cancers to be at epidemic levels (see sidebar).
Cancers of the head and neck region are difficult cancers. Treatment often limits a person's ability to swallow, which in turn greatly affects his or her diet and nutrition. Surgery may change the appearance and function of a person's face. Sometimes patients lose their sense of taste.
"Head and neck cancers affect a part of our body that we use as social creatures," says Amy Chen, head and neck surgeon who started the tumor board in 2001.
"That's what makes it so critical to have this collaborative care. This is a cancer that can devastate its patients. It affects their ability to be social, at a party, at a wedding, at dinner with friends. If you have surgery, everyone knows. It's a very visible disease."
Head and neck cancer patients also experience the effects of stigma associated with cancers that others sometimes believe the patients brought on themselves. Because tobacco and alcohol use are risk factors, head and neck cancer patients, like those with lung cancer, sometimes "don't have the sympathy" of other cancer patients, says Scott Kono, one of the newest members of the team.
"That's one of the things that attracted me to the field, sort of the underdog aspect of these patients," says Kono, who joined Winship about a year and a half ago.
Head and neck cancer patients need special care in that regard, Kono says, and they receive it at Winship. "There's a high incidence of depression, and a high suicide rate compared with other cancers," Kono explains. That may be related to treatment intensity, a long recovery period, and people being cut off from their social network because of impediments to their speech and swallowing, and to effects on their appearance, says Kono. These issues too are discussed at tumor board.
Surgeons such as Chen are often the discussion leaders. As the team discusses each case, all in attendance pay close attention to Power Point slides being displayed at the front of the room. CT, MRI, and PET scans, as well as photographs, are used. Surgeon Bill Grist stands at the front, presenting cases and asking and answering questions not only about best surgical interventions but also about the psycho-social issues patients are facing. The group does not move on to the next patient until all questions relating to the patient at hand are answered.
It's not all doctors and nurses here; social worker Carol Rivera and speech pathologist Meryl Kaufman are also in attendance, guaranteeing patients a full spectrum of care. Kaufman explains that patients see speech pathologists before treatment even begins. Giving patients exercises not only helps them maintain muscle tone in their necks and throats but also helps them have some feeling of control as they go through treatment, Kaufman explains.
"Most hospitals don't have disease-specific tumor boards," says Chen, "and the patient is comforted by knowing that we have such collaboration."
Jim Stapleton, a retired Army colonel and head and neck cancer survivor, says he received "phenomenal care" at Winship. He is so appreciative that he brings pastries and coffee every single Tuesday morning from Highland Bakery, whose owner Stacey Eames even contributes by giving Jim a discounted rate because it's Winship. Although Stapleton finished treatment nearly five years ago, he wants to do what he can to show his gratitude.
"These guys saved my life," Stapleton says. "I'm impressed that they meet this early in the morning. It just shows their tremendous dedication."
Patients do benefit medically from such coordinated care, Chen says.
Allison Del Medico was diagnosed with a rare salivary gland tumor last year. Now cancer-free, here she enjoys a moment with daughter Sloane.
"There's evidence showing that aggressive, supportive care improves outcomes," she says. "Instead of everyone going up for a pop fly, thinking someone else has it and the ball gets dropped, here the ball doesn't get dropped."
Greg Gregory of Atlanta was diagnosed with Stage IV throat cancer in April, 2011. Before the year was out, he was healthy and traveling in Asia. Chen was his surgeon and also the "captain" of his team.
"You need somebody you can look up to and say ‘she's in charge,'" Gregory says of Chen. "You want to salute her because you have so much confidence in her."
As soon as he praises Chen, other names pop up, too. It's as if the team is so interwoven that patients can't think about one caregiver without wanting to praise all the rest of the team.
"Oh, and Dr. Saba (Nabil) is just a splendid man with a splendid staff," Gregory says.
For his part, Saba simply says that it's a privilege to be part of patients' lives and to help them recover.
"It makes me feel so grateful that we do have such a system and such a program in place that we do make such a difference in people's lives," he says.
The exceptional team work is especially important in the treatment of head and neck cancers, explains Grist.
"This is a very labor-intensive cancer to treat," says Grist, "and tumor board really has facilitated communication so that patients are getting the best care possible."
Gregory summarizes it this way:
"The whole thing is, you've got the Winship team, and you've embraced them, and they embrace you. They understand you as a person. It gives you so much confidence, which you need if you're going to win this battle," he says. "I don't know how Winship accumulated all that talent in one place, but it's pretty amazing."
Research that resonates
Winship's head and neck cancer program has a strong research focus that supports its patient care. Because head and neck cancers can be challenging to treat and because no effective screening tool exists for them, the Winship approach to these cancers is aggressive.
For example, Winship, with National Cancer Institute SPORE grant support, has awarded 36 development awards to young investigators, says Shin.
The robust SPORE research team is involved in at least a dozen clinical trials, including trials evaluating the best use of concurrent radiation and chemotherapy in those with high-risk squamous cell cancer, which accounts for a large percentage of head and neck tumors.
In addition, researchers are studying chemoprevention, nanotechnology therapies, and methods of blocking key pathways that cancer cells need to thrive.
Consider the work of Shin's lab. Georgia Chen and Ruhul Amin are looking at whether pre-malignant head and neck lesions can be prevented from becoming head and neck cancer with the use of green tea polyphenon E.
Dong Moon Shin, associate director of Winship and director of the head and neck cancer program, says he is proud of his dedicated team of researchers, physicians, and nurses, who strive hard through teamwork "to make the best decision for patient care."
Chen, Shin, Xianghong Peng, Xu Wang, Ximei Qian, Shuming Nie, and Beitler are studying the significance of circulating tumor cells detected by gold nanoparticles. These so-called CTCs can help doctors determine whether disease has metastasized.
Another important study is examining whether COX-2 inhibitors—the same type of drug that prevents inflammation-induced arthritis—in combination with EGFR tyrosine kinase inhibitors (TKIs) such as erlotinib—can prevent cancers from pre-cancerous lesions. The approach makes sense. COX-2 expression is common in the upper aerodigestive tract, and COX-2 inhibitors already are being developed in chemoprevention for colon cancer.
Other trials are looking at what happens when COX-2 inhibitors are combined with EGFR-TKIs.
"The result (of the combination) is highly synergistic to inhibit cancer progression," Shin says.
Another clinical trial is assessing the combination of EGFR-TKIs with green tea. That combination also works synergistically to inhibit tumor growth, Shin explains.
The SPORE grant also includes a pathology and statistics core. And the program features a strong career development program (CDP) and research development program (RDP) to nurture young investigators and developing science. The CDP program, under the direction of Winship Deputy Director Fadlo R. Khuri, gave 19 awards. The RDP, led by Jin-Tang Dong, gave 17 awards over the past five years.
"Such pilot programs of research clearly help young investigators to devote themselves to perform meaningful research in head and neck cancer," Shin says.
Care that counts
It's 6:30 p.m. on another February day. Grist is the guest speaker at a head and neck cancer survivors' support group, which surgeon Chen and nurse Arlene Kehir started years ago. Beitler is there too. The room is packed.
Grist presents information on the rising incidence of oropharyngeal cancers caused by HPV16. The rising incidence concerns Grist, Beitler, and other head and neck cancer doctors.
Both doctors express a sense of urgency in finding answers to why millions of people clear the virus every year and why others don't. They also want to understand how cells become cancerous when infected by the virus. Yet another area of research at Winship on HPV16 focuses on treatment of these patients. Research and experience have shown that these patients fare better than other patients with head and neck cancer. So Winship is conducting and participating in clinical trials, explains Beitler, to study whether de-intensifying treatment in this patient group might work. For example, might patients do just as well with cetuximab, a monoclonal antibody without a range of side effects, as they do on standard therapy with cisplatin, which does have a range of significant side effects.
"You really have to study at night to keep up with the changes," says Beitler, who also happens to be a flight surgeon in the National Guard (a colonel) and who also holds an MBA ("The main thing I learned is that I care more about treating patients than making money," he says).
"Howard and Lynne Halpern, left and center, recently made a $2.5 million planned gift to honor their friend and physician Fadlo R. Khuri, right, and to support the development of new therapies for head and neck cancers.
Marcy Leamy is only one of several at the support group who talk about how that dedication has made a difference in their lives.
"Dr. Beitler saved my dad's life," says Leamy, whose father Alfred, a mathematician, recently underwent surgery for head and neck cancer. "My father is from Tampa, and they called up here and said, ‘We have a stage IV; can you see him?'"
Beitler did. Albert needed surgery right away. "He walked us up to the surgeon's office that very minute," Marcy recalls. "They said, ‘We can't see him for a month.' Dr. Beitler said, ‘double-book him.' And they did."
"He's phenomenal," says Allison Del Medico, a 30-year-old mother who was diagnosed with a rare salivary gland tumor last year. "There aren't words to describe how amazing he's been."
Beitler emails her with MRI results and then calls to make sure she understands the results, Allison says.
That said, "he won't let you stray," Del Medico and others say.
"I asked if I could just have one glass of wine recently, and he said, ‘absolutely not.'"
"He told me, ‘this isn't Burger King.' You don't get to have it your way,'" another patient, Jim Deweerth, chimes in.
Another patient recalls how Beitler and Scott Kono met him in the emergency room one Monday at 2 a.m.
Beitler stresses that everyone on the head and neck cancer team has the same dedication. He quotes from a former mentor that it is not only a duty to serve others but also a joy.
"It's a great way to spend your life," says Beitler.
While patients with HPV16-related cancers generally have better outcomes than patients without an HPV16 association, cancers caused by HPV16 are still a matter of great concern at Winship.
"It's an epidemic," says Dong Moon Shin.
Shin and others point to the growing numbers of patients with HPV16-associated head and neck cancer in their 30s and 40s without traditional risk factors for head and neck cancer.
HPV16 infection is generally caused by sexual contact, but one of the puzzling parts about the virus is that not all people who are infected with HPV16, which includes about 20 million American adults, will develop cancer.
Researchers do know that the virus can be latent for 10 years or more, Bill Grist explained recently at a survivors' support group meeting. And they also know that having six or more oral sex partners in one's lifetime increases a person's risk of developing oropharyngeal cancer nine times. Compare that to the increased risk caused by drinking—2.5 times—and smoking—3 times—and it's easy to understand the concern.
Winship researchers are trying to understand how HPV16 is involved with carcinogenesis and why some people develop cancer from it and others do not.
Because patients with HPV16-related cancer fare better in many cases than those with other kinds of head and neck cancer, Winship doctors are also conducting trials to determine whether some of those cases need as much treatment as others do.
Shin and others were very supportive of guidelines suggested last fall to vaccinate boys and girls with a vaccine that can prevent HPV16 infection. Winship experts suggest that parents of boys and girls talk to their pediatricians about the vaccine to protect against HPV16.