DukeHealth.org: Duke Health Features

Poll: How Often Do You Wear Sunscreen?

Wed, 25 Apr 2012 14:35:18 -0400

To help you know what sunscreens are most effective in preventing skin cancer and early skin aging, the U.S. Food and Drug Administration is implementing new sunscreen labeling requirements that go into effect this summer.

Sunscreens that are labeled "broad spectrum" must provide protection from both UVA and UVB rays.

The FDA recommends regularly wearing a broad spectrum sunscreen of at least SPF 15 or higher to prevent the effects of sun damage over time.

Do you wear sunscreen every day? Take our poll and let us know.

Do you wear sunscreen every day?

Faces of Hope: Duke Cancer Patient Stories

Thu, 19 Apr 2012 12:56:57 -0400

View a slideshow of people whose lives have been changed through research at Duke Cancer Institute.

(To view this slideshow, please view this article on DukeHealth.org.)

Then, Now, Next: Transforming Cancer Care at Duke

Wed, 18 Apr 2012 16:02:12 -0400

Evelyn Morgan

When Evelyn Morgan was hired as Duke’s first oncology clinical nurse specialist in 1967, she embraced her role. “I was drawn to the field because it seemed romantic and challenging. We were going to cure people!” she says. “But often what we gave patients could prove to be no good.”

In those early days, when patients often died from the side effects of new treatments rather than the cancer itself, researchers and doctors all over the country were desperate for a better way. Just a few years after Morgan started work on the wards, in the early 1970s, the government would declare “war” on the cancer menace and create the nation’s first eight comprehensive cancer centers -- one of which was at Duke.

In the decades that followed, Duke scientists and clinicians contributed, discovery by discovery, to a growing arsenal of tactics to prevent and treat the once-unstoppable disease -- offering new hope to patients in North Carolina and all over the world.

Yet while many have benefited from those advances, the dream of curing people too often remains elusive. With a vision for accelerating progress, Victor J. Dzau, MD, chancellor for health affairs at Duke, led the conceptualization and creation of the Duke Cancer Institute, which was ultimately launched in 2010.

The Duke Cancer Institute represents a total restructuring of clinical care and research designed to generate innovative ideas and speed the translation of scientific discoveries into advances in care. This new approach to cancer care and research was catapulted forward in February 2012 with the opening of the new Duke Cancer Center, where those treatment advances will be delivered to patients in a far more focused and patient-friendly manner than ever before.

“We’ve come so far in the generation since the war on cancer was declared,” says Michael B. Kastan, MD, PhD, executive director of the Duke Cancer Institute. “But today truly is the beginning of a new era for cancer patients at Duke. We are determined to transform care from diagnosis through treatment and survivorship, making our clinical approach more patient-centered, delivering treatments that are more effective and less toxic, and helping each patient not only survive -- but thrive.”

The Case of the Brain Tumor Center

Barnes Woodhall, MD

The upward trajectory of cancer care at Duke can be clearly traced in the rise of one of its shining stars, the Preston Robert Tisch Brain Tumor Center. In 1937, Barnes Woodhall, MD, came to Duke as its first chief of neurosurgery (and the only neurosurgeon in North Carolina).

He established at Duke one of the first brain tumor programs in the nation -- a highly focused program, offering just one treatment: surgical tumor excision. For decades, surgery remained essentially the only treatment for brain tumor patients, even when Darell Bigner, MD, PhD, now director of the brain tumor center, arrived at Duke in 1963. “Patients would die within months,” he says.

Darell Bigner, MD, PhD

The brain tumor group was determined to find a better way -- as evidenced by a history of major breakthroughs, which helped establish Duke’s reputation as a leader in care and research for all cancers.

In the 1950s, Woodhall became one of the first physicians to use chemotherapy -- nitrogen mustard -- for brain tumors, albeit with limited success. He also pioneered the use of animal models to test chemotherapy for the treatment of brain tumors.

Henry Friedman, MD

In the 1980s, Duke researchers worked with the National Cancer Institute to establish the Brain Tumor Study Group, which introduced radiation therapy as a treatment option. In the 1990s, Duke’s Henry Friedman, MD, worked with pharmaceutical companies and participated in national trials that led to the approval of temozolomide (Temodar), which significantly prolonged survival.

In 2007, a Duke pilot study led by Friedman and James Vredenburgh, MD, found that bevacizumab (Avastin) -- one of a new category of drugs which Duke studies had shown to cut off tumors’ blood supply -- could slow the growth of glioblastoma multiforme (GBM), the most common and deadly form of brain tumor. In 2008, John Sampson, MD, PhD, presented evidence that a vaccine aimed at inducing immunity to GBMs may stave off recurrence and more than double survival times. And in 2011, Lee Jones, PhD, added a new treatment to the mix by showing that brisk, regular exercise may also extend survival.

Allan Friedman, MD

As the advances came from every angle, patients came from all over to Duke’s by-now world-famous brain tumor team. And it truly had become a team, offering not just surgery but medical and radiation treatments, plus extensive support services.

Today, specialists of all stripes work closely together to formulate the best treatment plan, increase the effectiveness of treatment, give the patient a better experience, and improve outcomes.

Hope has become the mantra of the Duke brain tumor group. “And there is hope, there’s just no question about it,” says chief neurosurgeon Allan Friedman, MD. “Not only does Duke bring brilliant science to bear in treating patients with cancer, but we treat the whole person and constantly strive to improve quality of life.”

Getting to Multi-D

The history of the brain tumor program illustrates the major trends that are driving care at the Duke Cancer Institute today: Unprecedented advances in technology and in drug development. A focus on the whole person and quality of life. And a commitment to bring all of those resources together for the patient.

Cancer researchers in the 1970s

Key to achieving that is the multidisciplinary clinic -- in which experts from every specialty come together to deliver integrated care that is completely focused on the needs of the patient.

Ideally, a multidisciplinary clinic means patients meet with all their specialists -- medical oncologist, radiation oncologist, surgeon, and others -- in one day, in the same place, and leave with a team-built plan for comprehensive care. In practice, that’s not easy to achieve. In fact, many cancer patients today still start their treatment based on advice from a single specialist.

Jeffrey Crawford, MD

“The true multidisciplinary clinic is rare,” says Kastan. “Only a handful of centers work this way -- not even most freestanding cancer centers do it. It is very complicated to have all the different disciplines together, to get physicians from across the departments and across clinical boundaries together for every patient. It’s challenging in most settings, and requires a concerted effort. Yet it is an absolute requisite for optimal care.”

That’s why leaders structured the new Duke Cancer Institute to make “multi-D” care a reality -- for every patient, in every clinic. To foster collaboration, DCI clinicians are organized by disease site (such as breast cancer or lung cancer), not by their discipline (i.e., surgery or medical oncology).

They also meet regularly with clinical and basic researchers interested in the same disease sites to generate new ideas for study. The new cancer center is physically designed to support the multidisciplinary approach, as well.

Early radiation oncology tools: state-of-the-art liquid chromatograph

“It is very resource-intensive in terms of physicians’ time,” says Joseph Moore, MD, a medical oncologist at Duke since 1975. “But for a patient, it’s very efficient. It is a very focused way of diagnosing and planning treatment.”

The benefits are already clear to those teams at Duke that practice multi-D care on a smaller scale. “We understood the value of this type of care early on,” says Jeffrey Crawford, MD, medical oncologist and associate director of the thoracic oncology group, who came to Duke as a resident in 1974. “It is critical for the patient to get that combined expertise. They come here for expertise, but they are often surprised to see just how much they have access to.”

Duke University Hospital, 1980

Multidisciplinary care may have flourished earlier at Duke than other centers because of the structure of tumor boards at Duke, adds Crawford. The tumor board is a standing meeting in which surgeons, medical oncologists, and radiation oncologist get together to review cases and discuss joint treatment plans.

“We never had a generic tumor board here -- they have always been disease-specific,” says Crawford. “The multidisciplinary clinic is an extension of that. Instead of waiting for the tumor board to meet, we’re able to bring together expertise for individual cases immediately. It’s like a live tumor board for the patient.”

A nuclear magnetic resonance imaging (MRI) scanner, 1983

For breast cancer, multidisciplinary care also works extraordinarily well, says Gary Lyman, MD. In Duke’s breast oncology group, he and other medical oncologists work closely together with specialists in not only surgery and radiation oncology but also imaging, pathology, and others in making the diagnosis, and with social workers, dieticians, physical therapists, and others in supportive care.

The effects are clear: “Over the past two decades, we have made tremendous progress in the treatment of breast cancer,” he says. “Today, depending on what numbers you look at, 80 to 90 percent of patients who present with early-stage breast cancer go on to cure. That kind of success has been made possible in part by the multidisciplinary approach, as we are making more informed and coordinated decisions earlier in the management of patients with breast cancer.”

Merciful Medicines, Precision Care

Another sea change in cancer care comes as a blessed relief. “Patients suffered so many side effects from chemotherapy,” Evelyn Morgan recalls of her early days as a clinical research nurse. “The nausea was what they feared most.” In fact, many antiemetics were originally developed as treatments for the side effects of chemotherapy.

“The introduction of effective antinausea medication in the late 1980s revolutionized care,” says Kevin Sowers, MSN, RN, president of Duke University Hospital, who began his career as a nurse on the hospital’s oncology ward.

“When I got started in this field in 1985, we treated cancer patients with chemotherapy in the hospital because of the nausea and vomiting. The advances in symptom management drugs changed everything, including moving much of cancer care to the outpatient setting.”

“Antiemetics changed the playing field,” agrees Crawford. “Once we could manage the nausea caused by platinum-based chemotherapy, we were able to further develop those drugs.” A few years later, he and others at Duke introduced another advance in symptom management by leading multicenter trials of GCSF (Neupogen), a drug approved by the FDA in 1991 to treat chemotherapy-related neutropenia by stimulating the growth of white blood cells.

Advances in technology have also contributed to making radiation treatment gentler—and more precise, says Christopher Willett, MD, chair of radiation oncology. Intensity-modulated radiation therapy and 3D radiation therapy have refined the delivery of radiation to treat tumors while minimizing effects on healthy tissue.

The introduction of imaging technology such as MRI and PET improved visualization and detection of cancers and the accuracy of treatment. And linear accelerators allow therapy to be delivered with extraordinary precision.

Today, “We’re working to define which patients would benefit from radiation therapy through imaging and, importantly, the unique biology of each cancer,” says Willett. “Our ultimate goal is to tailor treatment to the individual patient. That is really where all of cancer care is going.”

The new class of drugs known as targeted therapies is a key step toward that aim. Duke researchers have played key roles in developing and testing many of these new therapies, including bevacizumab (Avastin) -- first approved by the FDA for colorectal cancer in 2004 -- and lapatinib (Tykerb), approved in 2007 for treatment of HER2-positive breast cancer.

Unlike chemotherapy drugs, which kill all rapidly dividing cells, targeted therapies inhibit molecular pathways specific to certain cancer cells. More focused than chemotherapies, they are less toxic -- and they also extend survival.

“When the war on cancer began in 1971, we didn’t have the tools we needed to fight cancer,” says Kastan. “Today, thanks to four decades of laboratory and clinical discoveries that are leading to earlier diagnoses and better therapeutic drugs, we see differences in many arenas, from acute leukemia to breast cancer to brain tumors. Where little hope could be offered to patients back then, we have many success stories now.

“Even in tumors that are very resistant to treatment -- pancreatic cancers, some lung tumors -- we now have nontoxic drugs that can increase survival by two or three months. That may not seem like much, but it’s promising since it tells us we’re heading in a good direction,” he adds.

“We’re learning that to really improve the cure rates, we need to refine our understanding of cancer and tumor biology, and have scientists and clinicians work hand-in-hand to apply that understanding to each person’s care. Our goal with the DCI is to create those opportunities that will continue to move us forward.”

Survivorship: A Measure of Success

More effective treatments have given rise to more cancer survivors -- once an anomaly, now a fast-growing group.

Lee Jones, PhD, scientific director of the Duke Center for Cancer Survivorship, believes it was about a decade ago that widespread attention began to be given to the particular needs of survivors. “There are about 13 million cancer survivors in the United States today. It’s a direct result of our progress in detecting and fighting cancer,” he says.

In fact, he notes, the percentage of people surviving cancer long-term has risen from 50 percent in 1975 to 67 percent by 2009.

Duke launched its survivorship center in 2005 to support cancer patients both during and after their treatment.

Tina Piccirilli

“We believe that individuals become cancer survivors at the moment of diagnosis and are survivors for the balance of life,” says director Tina Piccirilli. That holistic view informs the center’s services, which include a wide range of educational and support programs from pharmaceutical and genetic counseling, to physical therapy and nutrition counseling, to support groups and social work. The center also leads research aimed at defining the role lifestyle interventions play in patients’ overall quality of life.

Lee Jones, PhD, studying exercise

For example, research by Jones and his colleagues has shown that not only does exercise improve how cancer patients feel during and after treatments, but it may also extend their lives.

“Cancer is out of their control, but exercise is not, and therefore is very empowering,” Jones says. “My goal is that one day exercise therapy will be considered part of standard of care for the treatment of many cancers, just like it is following a diagnosis of cardiac disease.”

In the new Duke Cancer Center, this increased emphasis on patients’ quality of life is evident at every turn -- from the café serving healthy foods to the educational resource center to the organization of clinical care.

Breast Cancer Survivors Clinic

“In this new facility, support services -- the dietician, social worker, counselors, and others -- are integrated into the clinical space along with the multidisciplinary care teams,” says Tracy Gosselin, MSN, RN, associate chief nursing officer for oncology services.

“This really is patient-centered care, where everything is focused on their comfort and efficiency. The whole building, and the whole experience we offer, says that we are there to promote their healing.”

That’s what it’s all about, agrees Kastan.

“The more we can support the patient physically, socially, and medically, the more likely they are to successfully complete their therapy -- and the more likely we are to cure them,” says Kastan.

“That remains our ultimate goal.”

CoreValve TAVI Trial Showing Impressive Early Results

Wed, 18 Apr 2012 14:02:58 -0400

G. Chad Hughes, MD

Will Neighbors, already a survivor of quadruple coronary artery bypass grafting and a lower right lobectomy to remove a lung tumor, had a heart attack in May 2011. The event required no immediate surgery, but it did exacerbate his aortic valve stenosis.

Neighbors first came to Duke from his home in southern Arkansas in 2008, when he was diagnosed with valve disease.

When he returned three years later, his doctors saw a once-active man laid low by his aortic valve stenosis. Neighbors was so short of breath, he would get dizzy and fall if he attempted to walk or to bend over to pick up an object.

He was ruled ineligible for open surgery because of the position of bypass grafts under his sternum. CoreValve -- an experimental, stent-based valve-replacement procedure -- was his only option for treatment. “It was this,” he says, “or nothing at all.”

Neighbors was among the early Duke participants in the Medtronic CoreValve transcatheter aortic valve implantation (TAVI) clinical trial.

Almost a year after the first CoreValve implant at Duke, it’s still too early to draw conclusions, but trial leaders say initial results are encouraging. That’s a positive sign in a study in which all patients are high-risk for valve treatment, and all patients have additional concomitant health problems, such as lung disease or kidney disease.

J. Kevin Harrison, MD

Because other stent-based valves have shown an increased risk of stroke compared to standard valve surgery, choosing patients cautiously is critical.

Cardiologist J. Kevin Harrison, MD, who along with cardiothoracic surgeon G. Chad Hughes, MD, leads the study at Duke, says that prospective study participants frequently tell him that their ability to remain somewhat independent is key to their quality of life.

They are interested in survival and having their symptoms improve, but if the cure is worse than the disease, they aren’t interested. “If they have a stroke and they’re left so that they can’t walk or they can’t function,” says Harrison, “you haven’t really helped them.”

Harrison and Hughes lead a large team performing the procedure. Despite the extensive preparation by the two physicians, Harrison jokes, “It’s like running a football team.”

They rely on a crew of about 15, including highly trained surgical and cath lab nurses and technicians, cardiothoracic anesthesiologists, and cardiac CT and echocardiography specialists. Electrophysiology staff implant and run temporary pacemakers to allow accurate valve positioning and to treat episodes of slow heart rates. Two people are assigned only to load the valve in the delivery catheter properly.

The doctors implanted Neighbors’s valve on July 23, 2011, a few days after his 79th birthday. Hours following the procedure, he walked the hospital hallway with assistance.

Neighbors now feels so good, he walks twice a day and is signing up for a 12-week physical rehab class. He’s also looking forward to driving again, which along with his reinstated vigor will give him freedom that was missing for three months. “I’m going to get loose,” he laughs, “and nobody’s going to catch me.”

To inquire about enrolling a patient in the CoreValve TAVI trial, call 919-681-3763.

Details About the CoreValve Trial

There are two cohorts to the CoreValve trial: The first includes only patients with severe aortic valve stenosis for whom open surgery is not an option. All of these patients receive the CoreValve.

The second cohort is patients who are high-risk for standard valve surgery. These participants are randomized one-to-one to receive either CoreValve or standard valve surgery.

Although Duke delayed its enrollment in the trial by four months to be sure the device had been thoroughly bench-tested for durability, it’s in the top five of 41 enrolling sites in the United States.

Banishing the Myth of Passive Knee Rehab

Wed, 18 Apr 2012 13:59:52 -0400

David Attarian, MD

Medicine is not immune to the seductions of tradition -- there are studies to prove it. “A lot of things that we do in medicine, we do because we’ve always done it, not because there are good data to support that practice,” says orthopaedic surgeon David Attarian, MD, who knows firsthand how difficult it can be to break “bad habits” in practice.

Knee replacement surgery has, for the past 30 years, made use of continuous passive motion (CPM) to aid recovery in patients.

The CPM machine -- a device that requires a fair amount of effort on the part of the nurse, therapist, or family member to put it on the patient without hurting the patient -- came into popularity after some data showed that it might help reduce drainage and increase a patient’s range of motion at discharge (which was, at that time, seven to 10 days after surgery).

Attarian estimates that CPM machines are still in use in as many as half of hospitals that perform total joint replacement. “Some hospitals use it as a way to control costs, because it reduces their need for therapists to be on hand,” he says. Moreover, patients have come to expect the CPM -- they hear previous patients talking about how it helped them recover, and they think they need it.

But here’s the thing -- current data don’t support it. Over the past 10 years, hospitals that specialize in total joint replacement have studied the use of CPM versus moving a patient rapidly into active therapy, says Attarian, and they’ve found that it is no better for a patient than introducing physical therapy shortly after the surgery.

Evidence-Based Care at Duke Orthopaedics

Duke’s Total Joint Coordination of Care Committee has developed a new protocol regarding knee replacement surgery. Instead of CPM, the patient receives his or her first physical therapy visit on the day of the surgery (or the following morning), and his rehabilitation focuses on active motion instead of passive.

Attarian led a Duke study of the protocol, and the results mirrored the data gathered at other institutions -- leaving out CPM reduces patient pain and resource drain by cutting out the burden of applying and removing the device, which requires two people and four to six hours’ worth of labor over the course of a day. And the patients have the same outcomes at discharge and three months out, compared to results from CPM patients.

While it took some time to convince patients and doctors alike, Attarian says, the protocol is now used 100 percent of the time at Duke.

Do As I Do: Duke Cardiologist Practices What He Teaches

Wed, 18 Apr 2012 13:53:19 -0400

Robert M. Califf, MD

Rob Califf was shocked when he discovered he had hypertension. It had been a few years since he’d paid much attention to his blood pressure -- then, in 2010, his doctor told him it was too high.

Considering Califf’s life and work, his high blood pressure is not surprising. He is an executive at a large corporation, he eats out frequently, he travels all over the world, he’s in his late 50s, and he doesn’t care for exercise.

But here’s the twist -- Rob Califf, MD, is Duke’s vice chancellor for clinical research, he’s a practicing cardiologist, he directs the Duke Translational Medicine Institute, and he’s one of the world’s foremost researchers in cardiovascular medicine.

Check It, Change It

Califf had already begun treatment for hypertension when he decided to enroll in a Duke-led, community-based quality improvement initiative designed to help residents of Durham County control their blood pressure. He was the first person to enroll in Check It, Change It, a grassroots effort that is an offshoot of Durham Health Innovations (DHI), a public-private-academic partnership that Califf helped found.

Check It, Change It is a unique model of integrated care for hypertension. The genesis of the project was when Califf and Duke won an award from the National Institutes of Health to investigate how medical researchers can translate findings more quickly from an academic setting into the community to improve population-based health.

With the award in hand and the knowledge that 30 percent of Durham County residents suffer from hypertension, DHI began to formulate an intervention strategy. Meanwhile, the American Heart Association (AHA) heard about the effort and contributed substantial funding.

The program began enrollment in December 2010 after hiring three physician assistants and seven community health coaches to serve as patient liaisons. These Check It, Change It staffers promoted the program heavily in busy community venues such as churches, mosques, barbershops, schools, libraries, and community centers.

“We wanted to drive blood pressure care outside of traditional health care settings into the community where people work, live, and play,” says Bimal Shah, MD, a Duke cardiologist who is co-principal investigator for Check It, Change It with fellow Duke cardiologist Kevin Thomas, MD, and Sharon Elliott-Bynum, PhD, executive director of community health nonprofit CAARE Inc.

Through eight participating clinics, program staff enrolled 2,045 Durham County residents. With the Check It, Change It team, participants designed a plan to reduce their blood pressure (BP), including diet and exercise modifications, hypertension educational counseling, and/or medication. Physician assistants monitored progress and followed up to make sure participants stayed on track.

Patients checked their own BP at least once a week, either at home or at blood pressure monitoring stations located in 17 convenient locations throughout the community.

The self-check stations automatically entered blood pressure measurements into the AHA’s Heart 360 Web portal, a tool that promotes data sharing with primary care providers and Check It, Change It staff. (Those monitoring at home entered their data on Heart 360 themselves.) The goal was a reduction in BP after six months of program participation.

Califf’s results have been good. He has lost 10 pounds, with a goal of losing five to 10 more; his blood pressure is controlled by one medication; and he works out at least 30 minutes a day on an elliptical machine.

His regular monitoring has allowed him to adjust the dosage of his medicine right away when he notices spikes in his BP. But it has been the human contact of Check It, Change It that he has found the most helpful.

“We know that people are busy and lead stressful, complex lives,” Califf says, noting that program staff helped him stay diligent. “They’ll get on the phone and give you a call if you haven’t entered your data, or your data doesn’t look good. Active follow-up and reminders are the most important thing.”

The intervention phase of Check It, Change It ended in February, and preliminary results are positive. If final results indicate success, organizers plan to extend the community-based model to other chronic health issues such as obesity, diabetes, and high cholesterol. They also hope that other communities will adopt the model.

ECMO -- Walking?

Wed, 18 Apr 2012 13:52:12 -0400

Jessica

In January 2010, 16-year-old Jessica, suffering from end-stage cystic fibrosis, was transferred to the Pediatric Intensive Care Unit (PICU) at Duke Children’s Hospital with hopes of receiving a double lung transplant.

Her lung failure was severe enough that she needed to be placed on extracorporeal membrane oxygenation (ECMO). Even with this machine acting as Jessica’s lungs, she was too sick and too weak to handle the transplant surgery.

Jessica was going to die unless she got much stronger, and fast.

The Duke team decided that Jessica’s only chance for survival would be to actively participate in a physical therapy program that could increase her strength while on ECMO life support.

Walking a pediatric patient on ECMO, the most extreme form of life support available, had never been done before, and would require careful planning and significant staff and technological resources.

But this unique ambulatory ECMO approach, developed by a multidisciplinary team led by director of lung transplantation David Zaas, MD, ECMO medical director Ira Cheifetz, MD, cardiothoracic surgeon R. Duane Davis, MD, and pediatric intensivist David Turner, MD, has allowed Jessica and two other extremely ill patients to receive healthy lungs -- and to thrive after transplantation.

“It’s a new way to deliver life support as a bridge to transplant,” says Zaas, “and we’ve shown that you can markedly decrease length of stay, improve outcomes, and lower hospital costs.”

Physical Therapy on ECMO

In this protocol, the ECMO cannula is implanted through the neck (as opposed to the groin) and sedation is completely turned off, so that the patient can undergo active physical therapy. It’s quite a sight to see.

“She’s attached to a tower of pumps and medicine lines,” says pediatric respiratory coordinator Lee Williford, describing the first application of the protocol on Jessica. “What’s more, she has a hole in her throat from the tracheotomy and her surgical interventions are fresh and cause pain. It was scary enough just to sit her upright, let alone have her walk. The only thing keeping her alive, the cannula coming out of her neck, could come out with one wrong step.”

“There is no chance that these patients would have survived without this innovative process, so we had to try it,” says Cheifetz.

Jessica was indeed able to become strong enough to walk while on ECMO, and she received her new lungs just weeks after starting the program. Jessica died unexpectedly a year after her transplant, but the lungs she received gave her a year of better quality of life than her cystic fibrosis had ever allowed.

Gina's Story

Gina Kosla

Another of the first patients to receive ambulatory ECMO, Gina Kosla, was airlifted to Duke on February 24, 2011, in acute respiratory failure.

Kosla has cystic fibrosis, and when she developed influenza the virus shut down her already clogged lungs. She was immediately put on a high-frequency oscillating ventilator, but she continued to worsen and was put on ECMO.

When she woke up, she was told that in order to receive a lung transplant, she needed to start walking. “I was nervous at first,” she says, “but I did what they told me.” In fact, she walked 700 feet while attached to the ECMO machine.

“It didn’t seem like a big deal to me. I love marine science and everyone kept talking about this fish tank down the hall, so I decided I was going to go see this fish tank.” Kosla got three to four hours of exercise a day in anticipation of her lung transplant.

She was put on the transplant list on her 20th birthday, and got her lungs six days later. She’s currently enjoying life and lungs back home in Maryland.

Zaas explains that these patients do well because the physical therapy helps them maintain muscle mass and avoid weakness associated with critical care, which means they are less likely to suffer the common transplant complications -- most of which don’t come from the transplanted lungs, but from the sickness of the patient prior to transplant.

“We are now trying to determine which other populations can benefit from this unique program,” says Cheifetz, “so that more children and young adults can receive this lifesaving measure.”

The team published an article on these cases in Critical Care Medicine in December 2011.

Biostatisticians: Adding to the Count

Wed, 18 Apr 2012 13:48:53 -0400

Gregory P. Samsa, PhD

Today’s studies of the smallest increments of a human -- the genome, the gene, the protein, the metabolite -- yield a tremendous amount of complex data.

That means that today’s biomedical research teams are increasingly reliant on biostatisticians -- people who have not only strong statistics skills but also a foundation in human biology, and the ability to communicate statistical principles to multidisciplinary research teams.

The demand for biostatisticians is outstripping the supply. Hence Duke’s new Master of Biostatistics Program, which welcomed its first class of 16 students this school year.

The two-year degree program provides mentored academic training in biostatistics, including experiential learning opportunities in authentic ongoing research.

“We wanted this to be different from a traditional master’s program,” says Greg Samsa, PhD, director of graduate studies for the Department of Biostatistics and Bioinformatics. “We wanted active, hands-on learning. Biostatistics is a relatively new and rapidly growing discipline, and these are the skills we know employers are looking for.”

The program provides a practice-based learning environment, so that graduates will leave the program with a portfolio that demonstrates their mastery of analytical skills, biological knowledge, and communication.

Found in Translation: Finding Better Cancer Therapies -- Faster

Tue, 17 Apr 2012 13:26:25 -0400

Sally Kornbluth, PhD

Sally Kornbluth, PhD, is a biologist who spends a lot of time thinking about frog eggs. She studies them to understand apoptosis, the cellular death programming that’s present in all normal frog (and human) cells, but becomes disrupted in cancer cells so that they proliferate unchecked.

By “totally pure chance,” she says, she happened to hear about the work of oncologist Neil Spector, MD, a Duke colleague who led the development of the breakthrough breast cancer drug lapatinib (Tykerb) and was looking for new ways to help women who become resistant to the drug.

Kornbluth’s work on apoptosis led the two researchers to a new approach -- they used an existing drug to suppress a protein that regulates tumor resistance, thereby resensitizing the tumors to lapatinib. They hope that someday soon this new treatment method will make its way towards a clinical trial.

Neil Spector, MD

This process of aligning bits and pieces of knowledge and ferrying them from a cell culture discovery to a human therapy is called translational research.

Currently the process takes about 15 years -- when it’s successful, that is. That’s not a terribly long time in the realm of science, but time is precious for patients. Speeding up that process -- and making it less a matter of chance than Kornbluth and Spector’s happenstance meeting -- is one of the driving ideas behind Duke’s massive reorganization of its cancer enterprise into the Duke Cancer Institute (DCI).

“Great strides have been made against cancer over the past few decades, but there are still too many people whose cancer cannot be effectively treated,” says Victor J. Dzau, MD, Duke’s chancellor for health affairs, who led the establishment of the DCI in 2010. “It’s clear that we need to accelerate progress against this devastating disease, which is why we created the DCI.”

Victor J. Dzau, MD

The unique structure of the DCI represents a more focused, integrated approach to the cancer problem that brings researchers and clinicians together to spark innovation across the spectrum of cancer types, Dzau says.

“Our vision is to transform cancer care by accelerating the translation of research discoveries into breakthrough treatments that improve patients’ experience and outcomes.”

Making the Right Connections

“Traditionally in universities, and in the biomedical industries, there have been excellent basic scientists working in the laboratory, and then there have been excellent physicians working in the clinic,” says Spector, who is co-director of the DCI’s Experimental Therapeutics research program.

Bridging the divides between bench and bedside -- or even among various benches -- is a significant challenge. Yet most cancer experts agree that it’s somewhere between these two worlds where the big advances in oncology will be made.

The Duke Cancer Institute was built to be the bridge.

It all starts with the framework, says Michael B. Kastan, MD, PhD, executive director of the DCI. The institute is designed not around various specialties and disciplines, but around the diseases it seeks to cure.

Like a grid of intersecting interests and skills, there are 10 disease groups for different tumor sites -- each one drawing together clinicians, clinical researchers, and basic scientists -- as well as nine National Cancer Institute-designated research programs focused on crosscutting interests such as radiation oncology, prevention, and cancer genomics.

Since the DCI was created, the disease groups have been meeting on a regular basis -- and creating new connections. “The DCI is juxtaposing people who have common interests, helping people know who their relevant partners are and sparking enthusiasm for new ideas,” says Kornbluth, who is vice dean for basic science in Duke’s medical school.

Kimberly L. Blackwell, MD

“For example, [breast oncologist] Kim Blackwell runs clinical trials on lapatinib. She’s a busy clinician; I’m living in a different world. But through interactions with Kim and other clinicians in the breast cancer working group, now I’m thinking, ‘Could we work together?’”

“There is much more communication among faculty, much more thought being given to clinical-trial protocol development in all areas,” Kastan says. “We believe that’s step one toward our goal,” which is essentially to do all phases of drug development under one roof, with fewer costs (both human and capital) and better results.

“New target identification, drug discovery, development, testing, and taking that into clinical trials -- we want to do the whole spectrum within the DCI.”

Sparking New Ideas

Paradigm shifts take time. But the DCI’s new way of attacking old challenges makes so much sense, Duke faculty members are embracing the change.

Donald McDonnell, PhD and Dan George, MD

Take Donald McDonnell, PhD. Professor and chair of the Department of Pharmacology & Cancer Biology and a specialist in the development of drugs that target prostate and breast cancers, McDonnell has been at Duke more than 15 years -- but until recently he had minimal interaction with clinicians looking at the other side of what he was looking at.

Now, thanks to the DCI, he’s leading a research project that involves colleagues from his own lab, his department, the university, and the medical center. “We have come together to produce something that’s made me phenomenally reinvigorated,” he says.

Dan George, MD, directs genitourinary medical oncology at Duke. “I’ve been here eight years, and though Donald and I have always had shared interests, we’ve never had the impetus to come together. It was really the DCI umbrella that gave us the priority to do that work.”

For patients with prostate cancer, lowering androgen levels is one of the best available therapies, but a certain percentage of men die from recurring cancer that persists even after inhibiting the production of androgens to nearly undetectable levels.

McDonnell and George explored new ways to explain how these tumor cells survive even when androgen is blocked, and have discovered a potential antitumor molecule that shows promise against these recurring cancers. They’re now in the process of translating their findings into human trials, relying on collaborations with even more groups across the university -- from chemists to imaging specialists.

“It’s been very rejuvenating to feel connected across the institution,” says George. “One great thing about academics is that this environment allows you to do things that you can’t do anywhere else.”

Tightening the Cycle of Innovation

The notion that a closer connection between scientists and clinicians could reap big rewards didn’t fall from the sky, of course. Some Duke teams are living proof.

Nelson Chao, MD

Nelson Chao, MD, works in stem cell transplantation, an area that he says is, by definition, translational. “This is a fairly new field, so a lot of what we’re doing is cutting-edge,” he says. “Our patients are terribly ill, and we’re always running trials to try to make things better.”

Toward that end, the Adult Blood and Marrow Program he leads formed a cohesive system of constantly going back to the lab to try to find new ways to treat the disease and reduce complications from the treatment. “For us,” he says, “the distance between the laboratory work in mice to humans is relatively short.”

Judging by the leaps made since Duke pioneered the use of cord blood in adult patients in 1996, the system works. Chao’s group conducted the first large study demonstrating success in transplanting stem cells from donors who are not fully matched.

They introduced chemotherapy that is less aggressive than standard practice -- thereby making transplant an option for patients who would otherwise be deemed too sick or too old. New research into hematopoiesis -- understanding what regulates the stem cells that give rise to blood -- is testing new ways to trigger stem-cell renewal. And multiple projects are under way to manipulate transplanted bone marrow to reduce or prevent graft-versus-host disease.

“Really, it’s a remarkable thing that we’re doing,” says Chao. “Nearly all patients can have a stem cell donor.” He credits the success in part to the fact that, in his group, the physicians are also scientists. “It works for what we do. It means the people in the labs understand what the problems really are, so it gives their work more of a focus.”

Chao says he believes the new DCI structure will encourage more groups to strengthen connections to laboratory-based faculty “who can help spin off discoveries to the clinic.” And, he adds, the DCI’s investment in clinical and research resources will lift all boats.

“The work we do is very resource-intensive,” he says. “I think the DCI will bring shared resources that will give us all more security. Having the right people is essential, but so is having the infrastructure.”

The Trouble with Targets

The timing of Duke’s investments in cancer research is critical -- it is a necessary adjustment to stay effective in the face of mushrooming numbers of cancer therapies.

Historically, the war on cancer has been a somewhat empiric one, based more on practical experience than on intimate understanding of cancer biology, says Spector.

“Take maximum tolerated dose, which is how most chemotherapies were developed years ago. To kill as many rapidly dividing cells as possible -- knowing that will unavoidably include some normal cells -- you had to set the dose to the limit of what people can stand, and then back down a bit.”

This has changed dramatically, says Kastan, thanks to molecular and cellular biology breakthroughs that have opened windows into the inner workings of malignant cells. From these new discoveries the drug arsenal has changed from one of shock-and-awe to more targeted missiles aimed at different cell processes.

“Over the last 40 years, the problem in cancer was that we’ve had only a handful of drugs we could use, and they were not very specific and they had a lot of toxicities,” Kastan says. “The problem in the next 20 years is going to be the opposite: we’re going to have too many drugs and not know how to use them.”

Indeed, many potentially effective drugs are at our fingertips. But our technologies and tools are outpacing our ability to interpret the information they provide.

“If there’s anything the era of genomics is teaching us, it’s that there’s no such thing as a single tumor type,” Kastan says. “Instead of lung cancer being a disease that’s treated by the typical three or four drugs, we’re going to have 20 subsets of lung cancer, each one treated with different drug combinations depending on its biochemistry and genetics.”

Figuring out those tumor subtypes, and then matching them with the right therapies, is the challenge of the future, he says. The less you know about the mechanism that a drug acts upon, the less you know about how the treatment works and how it will behave in the clinic.

“Then you risk spending five years in clinical trials, coming up with a ho-hum result in patients, and having no information to figure out how to make it better or why it didn’t work,” says Spector. The drug goes on a shelf, collecting dust, when it could quite possibly be effective in a different tumor.

This nearly happened in the case of the new kinase inhibitors for lung cancer, Kastan notes. These drugs are highly effective, but only in a small percentage of patients. “And they almost missed it. The researchers just barely noticed that a small subset of people in the trials were responding, and they eventually figured out that those patients had a specific mutation targeted by the drug. It may only work in 10 percent of lung cancer patients -- but you know, that’s 10 percent.”

To find those needles in the haystack, to actually deliver on the ideas generated by its new collaborative model, the DCI plans to strengthen the pipeline from preclinical testing to clinical research.

“We’re going to have to know much more about the exact setting in which a drug may be useful before we take it into trials in humans,” says Kastan. Toward that end, “We plan to develop better animal model systems of cancer so that we can improve our understanding of the biology of tumors and test these new therapies more efficiently. That way we have lots of information at the outset to tell us how to test the drugs in people -- and in which people.”

Complementing that resource, the DCI is building an enormous data warehouse of tissue samples from tumors biopsied at Duke, so researchers can learn more about the molecular pathology of every type of cancer.

“We need these samples to conduct experiments that will help us understand the potential application of each discovery, and information on patient outcomes to understand how it might be relevant,” says Spector. “Duke is one of only a handful of places in the world with the capability to build a database of this magnitude. The more patients we care for, the larger the database will be, and the greater the impact it will have on the future of cancer research and care.”

DCI leaders have also been working over the past year to strengthen the infrastructure for cancer clinical trials, increasing the involvement of biostatisticians to improve data collection and analysis. “That way,” says Kastan, “we know when we’re finished, we’ll get an answer that will be interpretable -- that we can learn from.”

Gathering the Troops

Clinical trials are what drive discoveries into practice, and the studies are fundamentally intertwined with patient care. The new Duke Cancer Center is designed to encourage patient participation in clinical research by simplifying a complicated process and placing it in a central location.

Because many clinical protocols are multidisciplinary -- with surgical, imaging, chemotherapy, and other components -- having all of those providers on the same site makes participation much easier.

The new building includes dedicated space for clinical trial consultation and coordination, making standard what was previously a rare luxury for clinical trial coordinators -- privacy and quiet space near patient exam rooms to discuss clinical trials, informed consent, and any questions a patient has about clinical research.

“To do great research, we have to bring everyone together -- oncologists, surgeons, biologists, pharmacologists, chemists, radiologists, and the support staff of nurses and coordinators,” says Kastan.

“It takes a village to do this right. And by following this paradigm, when we do clinical trials in patients we will already have learned so much from preclinical testing that we can design trials more effectively. That means it takes fewer patients to have a bigger impact, it costs a lot less money, and we make advances faster.

“At Duke, our goal is not just to take great care of patients. It’s to take great care of them and to cure them,” says Kastan. “You can do that only through research.”

Introducing the New Duke Cancer Center

Fri, 13 Apr 2012 12:42:21 -0400

On February 27, 2012, a new landmark opened its doors on Duke’s medical center campus—the seven-story, 267,000-square-foot Duke Cancer Center. More than just state-of-the-art space, it’s an environment designed to transform the experience of every patient welcomed inside.

One of the first patients ever to step inside the new Duke Cancer Center was there long before opening day.

Back in October 2011, 80-year-old Laurence DeCarolis donned hard hat, orange vest, and safety glasses to be escorted across a muddy courtyard bustling with heavy equipment to the building-in-progress. DeCarolis, a leukemia survivor, and his wife, Elizabeth -- both longtime volunteers with Duke’s Cancer Patient Support Program -- had been invited to take part in a walk-through test of the facility’s wayfinding signage.

Along with other volunteers, they navigated their way to five sample appointment locations following temporary paper signs, and then offered feedback to help make sure the permanent signage would clearly direct patients to their destinations.

The navigation test was one of many times during the multiyear planning and construction process that patients, faculty, staff, and volunteers pitched in to make this new building the best possible environment for delivering and receiving cancer care. And the team effort toward that shared goal has produced a place that’s truly remarkable, says DeCarolis.

“You walk in and just say, ‘Oh boy.’ The initial reaction is one of awe, with that fantastic atrium. And then as you come in you see all the special touches, like the host stations with complimentary beverages and snacks and the wonderful resource room and the lounge areas where you can look out into natural light. You can tell that so much thought has gone in to making patients comfortable.”

Critical Needs -- and Creature Comforts

The Duke Cancer Center has in fact required years of thoughtful planning and concerted effort. The idea of creating a dedicated cancer center at Duke began taking shape in the mid-2000s, when it became clear that existing facilities were neither designed for the way cancer care was evolving nor sufficient to meet the growing demand for services.

Not only is the Duke Cancer Institute (DCI) currently serving more than 50,000 patients a year, forecasts project a 15.3 percent increase in new cancer cases in North Carolina between 2010 and 2015 -- and a 22.4 percent increase in the greater Triangle region that is Duke’s home base.

Far beyond simply adding space to accommodate more patients, though, “We saw a real opportunity to create an environment that would dramatically improve the patient experience,” says Kevin Sowers, MSN, RN, president of Duke University Hospital.

“Our providers have always put the patients first, but older facilities didn’t always support that -- they were more sterile environments designed primarily for clinical efficiency. The new cancer center is designed from the ground up with the patient in mind.”

In fact, patients -- including DeCarolis and many others -- helped inform the design, providing input in early focus groups that was complemented with extensive research and additional suggestions from caregiver teams. “We really wanted to listen to what people found challenging and what we could do to make the whole experience better for them,” says DCI administrator Carolyn Carpenter.

For example, in the old space, family members often overflowed from crowded waiting rooms into the hallway. Research showed that patients brought an average of 3.5 friends or family members with them, so the new building was designed with ample, living-room-like waiting areas.

For the 120 patients who receive chemotherapy each day, the new facility offers options of cubicles for privacy, a bright communal space for chatting, or even receiving treatment on the rooftop terrace on pleasant days. And healing spaces such as a quiet room for meditation are complemented by practical amenities like a boutique, a pharmacy, an educational resource center, and a café serving healthy foods -- reflecting the focus on whole-person care.

“The new cancer center is a wonderful, beautiful environment in which to deliver the very best cancer care,” says William J. Fulkerson Jr., MD, executive vice president of Duke University Health System. “Caring for our patients, their loved ones, and each other -- that’s what it’s all about.”

An Environment for Optimal Care

Beyond providing a comfortable and welcoming environment, the Duke Cancer Center will also enhance the leading-edge care Duke Cancer Institute is known for, says DCI executive director Michael B. Kastan, MD, PhD.

One important change is that the facility brings together almost all cancer clinical services on the main medical campus, meaning that patients no longer have to travel to far-flung locations to see multiple specialists. Instead, most of the DCI’s 100-plus board-certified physicians and 500 clinical staff will come together in multidisciplinary teams organized by disease type -- so that patients will have access to a full range of expertise in one convenient setting.

“It’s one-stop care delivery,” says Kastan. “The providers’ visits are all coordinated and everyone comes to the patient, which not only makes for a better patient experience but better medical care, because communication and efficiency are enhanced by the subspecialists being in close proximity. We’re also building survivorship services around that multidisciplinary care -- activities like social work, nutritional counseling, all the things we do to help the patient thrive during and after their treatment will be much easier to deliver with this kind of geography.”

The expanded space provides an opportunity to enhance these kinds of services, adds Carpenter.

“With space organized around disease groups, we can accommodate additional staff to enhance the depth of specialized care we offer. We haven’t historically had a dietician especially for breast and ovarian cancer, for example, but now there will be one embedded on the floor where those services are located. We’ll have genetic counselors, new-patient coordinators, family and marriage therapists, and pharmacists dedicated to focusing on specific patient populations, whether it’s prostate cancer or head and neck cancer. We want to give patients easy access to a total range of expertise.”

Designed for Progress

The new facility is also designed to bolster clinical research -- a key differentiator for the Duke Cancer Institute, which currently conducts around 700 clinical trials of investigational new cancer therapies and treatment approaches at any given time.

While these trials can provide patients with treatment options they will find nowhere else, it wasn’t always easy in the past for trial coordinators to find private space to discuss enrollment opportunities with patients. The new facility not only includes dedicated private rooms for these consultations, but will actually make clinical investigation itself easier, says Kastan.

“Many clinical protocols are multidisciplinary in nature, with surgery, imaging, and chemotherapy components. Having those specialists together in one setting, along with dedicated nurses who are in tune with every aspect of the treatment protocols, will make it easier to conduct complex trials.”

In such ways, he adds, the building supports the overarching vision for the DCI, which was created in 2010 under the leadership of Duke chancellor for health affairs Victor J. Dzau, MD, to accelerate the translation of research discoveries into improved patient care.

“This is going to be a sea change in patients’ experience,” Kastan says. “The opening of this new facility, combined with the creation of the DCI, will enable multidisciplinary teamwork, facilitate the clinical research enterprise, and make care more effective, efficient, and patient-friendly. It’s really making cancer care what it should be -- an endeavor where everything starts and ends with the patient in mind.”

Visual Tour of the Duke Cancer Center

The following slideshow offers a brief glimpse into what you can expect when you visit the Duke Cancer Center.

(To view this slideshow, please view this article on DukeHealth.org.)

Translational Research: Moving Discoveries from the Lab to the Clinic

Fri, 13 Apr 2012 10:12:37 -0400

Duke oncologist Neil Spector, MD, is co-director of the Experimental Therapeutics Program at the Duke Cancer Institute (DCI).

Neil Spector, MDHe is recognized internationally for his leadership in the development of cancer drugs such as Tykerb. Spector came to Duke in 2006 from GlaxoSmithKline to direct the DCI’s efforts to translate basic science discoveries in the laboratory into advanced care for our cancer patients.

What is translational research?

Spector: Translational research is taking knowledge developed and insight gained in the laboratory, and applying it in the clinic in order to enhance detection, treatment, prediction of outcomes, and prevention of disease in people.

Essentially, it is bridging the gap between the science being done in the lab, and the clinic where patients are treated.

We often hear in the media about great scientific discoveries, like a new gene identified in fruit flies, for instance. And the researchers always say, “At some point, we hope this will help people with cancer.”

Since most of us will be touched by disease at some point in our lives, we all want to see those great discoveries applied to advancing treatment and outcomes. That’s what translational research is all about.

Who does this type of research, and why is  it important? 

Spector: You never know where the next big advances in cancer treatment are going to come from. The key is to have people who are thinking: “How does that discovery potentially apply to patient care?”

Traditionally there have been excellent basic scientists hard at work in university and corporate laboratories, and then there have been excellent physicians working in hospitals and clinics, but it was difficult to bridge that gap.

It’s essential that we can think in both worlds -- so we can understand the science and say, “Well, maybe that discovery in Alzheimer’s disease has some bearing on bladder cancer,” or vice versa.

And increasingly, through physician-scientist training programs and through the addition of translational research training in medical schools and doctoral programs, we are gaining more people from both the medical and science worlds who have that mindset and that ability to bridge the divide.

How is the Duke Cancer Institute involved  in translational research? 

Spector: To continue to be a world-class center for cancer care and research, the DCI must have a world-class program in translational research. Building that program here is a top priority.

We have brilliant investigators working in cancer genetics, biology, pharmacology, and other disciplines and making important discoveries.

The Duke Cancer Institute is committed to making it easier for our basic scientists and clinicians to collaborate in order to translate these discoveries into advanced care for our patients through new medications, imaging technologies, diagnostic tools, and other advances.

Translating our home-grown research is a big challenge, since academic medical centers have not historically been geared toward doing that -- a role traditionally filled by pharmaceutical and biotechnology companies.

Because industry now considers discovery research too high a risk for their business models, the responsibility for drug and device development has been shifting from industry to academia. More and more, institutions like Duke are being called upon to lead the way.

At the DCI, our goal is to build our capacity to help our scientists and clinicians move their research from the laboratory to the clinic as efficiently and effectively as possible.

One way we are doing that is through our Experimental Therapeutics Program, which interfaces with basic and clinical investigators, providing the expertise to help Duke investigators move their projects forward, whether through internal resources or through strategic alliances with partners beyond Duke.

One of our biggest projects is to build a tissue database of every cancer biopsied at Duke, so that we can track the molecular pathology of cancers and correlate the molecular profile of cancers with clinical outcomes.

Having a database of this caliber is a critical aspect of translational research, because we need these tissue samples to help us understand the clinical relevance and potential diagnostic and therapeutic application of discoveries made in the laboratory. Duke is one of only a handful of institutions in the world with the capability to build a database of this magnitude.

The more patients we care for, the larger the database will be, and the greater the value and impact it will have on the future of cancer research and patient care.

What are some other examples of translational research taking place at Duke? 

Spector: An exciting example of translational research at Duke is the work of Dr. Mark Dewhirst, who studies the effects of heat treatment on tumors.

In the lab, Dr. Dewhirst developed heat-sensitive “nanoparticles” that can carry chemotherapy drugs to a tumor when injected into the bloodstream. Then, when the tumor is heated, the nanoparticles release the drug directly into the tumor.

This technology is now being used in a clinical trial to treat recurrence of breast cancer. It also could be used to treat other cancers.

In another Duke laboratory, physician-scientist Dr. John Sampson has developed a vaccine that has shown encouraging preliminary results in clinical trials for treating some glioblastomas, the most aggressive type of brain tumor.

And Dr. Donald McDonnell, chair of Duke’s Department of Pharmacology and Cancer Biology, has developed anti-estrogen approaches that are being tested in women who have estrogen receptor-positive breast cancer that has become resistant to standard therapies.

How does the Duke Cancer Institute impact translational research? 

Spector: The vision of the DCI for Dr. Victor Dzau, Duke chancellor for health affairs, is to bring together clinicians and basic science researchers who are now spread across the Duke campus, so that they can regularly meet, exchange ideas, brainstorm, and problem-solve.

This type of interaction is critical to our ability to translate research effectively from the lab to the patient. That has begun to happen more and more at Duke.

And the new Cancer Center will only enhance our ability for collaboration among physicians and scientists and to inform and educate our patients about new and innovative treatment options.

All in all, this building represents an important step forward for the DCI in our commitment to push the boundaries to improve outcomes for our patients.

First Impressions: One Patient's Experience at the Duke Cancer Center

Fri, 13 Apr 2012 10:04:47 -0400

Over the course of four days in December 2011, Anna Watson Blair’s life was turned upside down. Just a week after Thanksgiving, the nurse and single mother of three started feeling dizzy and off-balance.

In early December, she had a car accident and knew something wasn’t right, so she made an appointment with her family physician for the following morning. The doctor was concerned, and arranged an immediate MRI.

Just five hours later, on December 2, Blair was back in her doctor’s office, where she received the harrowing news: she had a brain tumor. “My doctor gave me a choice but recommended I go to Duke,” Blair recalls of that overwhelming day. “I wanted to go to Duke, too.”

Friends helped make arrangements, and by Saturday, Blair was admitted to Duke University Hospital for surgery to remove the tumor. On Monday morning, Allan Friedman, MD, co-deputy director of the Preston Robert Tisch Brain Tumor Center, removed the brain tumor.

“I was very confident I was in the right place,” she says. “Duke has a lot of resources to help me cope with my situation.”

After a week at Duke, Blair moved to Durham Regional Hospital (part of Duke University Health System) for rehabilitation, where she spent hours each day working with physical, occupational, and speech therapists. She made excellent progress, and just before Christmas moved back home where she received support from her “village of care” composed of her sister, brothers, parents, nieces, and friends.

After surgery, Blair underwent daily radiation treatment for six weeks under the direction of radiation oncologist John Kirkpatrick, MD, PhD. She is also taking part in a novel phase I trial that is studying the combination of radiation, the FDA-approved drug temozolomide, and an experimental drug, under the direction of neuro-oncologist Annick Desjardins, MD.

“We believe in a multi-disciplinary approach to care,” explains Kirkpatrick, “with the surgeon, neuro-oncologist, radiation oncologist, and many other specialists working together to develop and implement the best treatment for each individual patient.”

As the new Duke Cancer Center opened, Blair was still making regular visits to see Desjardins and Kirkpatrick to monitor her condition and determine what, if any, additional treatment will be needed.

‘It’s So Beautiful and Comfortable’

Blair’s first visit to the new Cancer Center came on February 29, two days after the new building officially opened to patients.

She arrived accompanied by her friend Fiona Strachan, who came from Australia to help her during her treatment and recovery. Their first stop was for laboratory tests and a medical check-in. As she sat in the lab’s spacious waiting area, Blair talked about the new facility.

(To view this slideshow, please view this article on DukeHealth.org.)

“I like the continuity, and how much the architecture is gorgeous. It is clear that a lot of thought went into the building’s design.”

Lab work complete, Blair took the elevator to Clinic 3-1: The Preston Robert Tisch Brain Tumor Center. The distance between the clinics and labs is much shorter in the new building, she noted. On the third floor, Blair was welcomed by several staff members, who explained that -- thanks to the pager she was given when she first registered at the lab -- she could actually check in for her clinic appointment using a nearby kiosk, and then relax in the Café, Resource Center, or anywhere else in the building until the clinic paged her.

Blair and Strachan had a cup of tea provided by a volunteer and enjoyed the view of the courtyard that is now under construction in front of the building until she was paged for her appointment.

“This is so nice,” Blair laughed as she entered the exam room. “The windows in the room are wonderful. It’s a gorgeous view.”

After her appointment, Blair and Strachan stopped by the Resource Center to borrow a meditation CD and picked up a new scarf at the Belk Boutique, which are located on the main floor across from the Quiet Room.

“I have never heard of a quiet room in a cancer center,” she says. “It provides a good feeling during such an overwhelming time. I’ll definitely spend time here again.” She was also touched by the quotes on the tiled Healing Path found on Level 00 and visible from all floors.

A Village for Cancer Care

Just as Blair talks about the “village” of friends and family that have provided support for her, Henry S. Friedman, MD, co-deputy director of the Preston Robert Tisch Brain Tumor Center at Duke, sees the new Cancer Center as one that fosters the “village” needed to fight cancer.

“This facility brings together all of the resources of Duke under one roof and improves our ability to collaborate with one another to ensure we provide the very best care for our patients,” he says. “This is a major advance for both the health care teams and our patients who battle cancer on a daily basis.”

For Blair, the building offers a warm and comfort- able place to come for check-ups, but it’s the people inside the building who really make the difference.

“I am so impressed with Duke employees and the level of genuine commitment they have for patients. Everyone is so thoughtful and caring.”

Feeling stronger every day, Blair walks daily and plans to participate in the Brain Tumor Center’s annual fundraising event, the Angels Among Us 5K and Family Fun Walk, on April 28 with her team, Anna Blair’s Flairs.

“I have been blessed every step of the way. I feel like I’m in such good hands at Duke and with my family and friends, and all that has really empowered me to be optimistic about beating this.”

Advance Care Planning: A Gift to Loved Ones

Thu, 12 Apr 2012 13:26:16 -0400

Discussing serious health problems and end-of-life issues with loved ones can seem so daunting that some people avoid it entirely.

But for family members bold and proactive enough to talk about these topics, creating an advance care directive -- guidelines for how a person wishes to be treated in case of a serious or terminal illness -- can provide immeasurable peace of mind for the whole family.

In recognition of how difficult these conversations can be, and how important they are, Duke Medicine’s volunteer Patient Advocacy Council created three short videos explaining what advance care planning is, why patients should file these documents, and how to go about the process.

What Is Advance Care Planning?

Advance care directives include a living will, which allows you to specify your medical preferences, and a health care power of attorney, which names the people you want to make health care decisions for you if you are unable.

Examples of the kinds of preferences a living will specifies include if you do or do not want artificial nutrition, and if you are willing to be placed on a breathing machine for an extended period of time.

If you were ever unable to speak for yourself, your health care power of attorney would ensure that your wishes were carried out. Some examples of these kinds of situations might be if you were unconscious after a traumatic injury, or if you began to suffer from dementia too severe to make your own decisions.

Brenda Radford, director of Guest Services at Duke University Hospital, says that because the federal government requires Duke to ask patients entering the hospital if they have an advance care directive, many people think they are required to have one. Radford says that it is not mandatory for patients to have this paperwork on file, but it is a very good idea.

“It’s a gift to their families,” she says. “If you wait until there’s a huge problem -- maybe someone is injured in an accident -- that’s not the time to start having those conversations. People aren’t always able to make rational decisions at that time of their life.”

Tough Topic, Gentle Touch

The videos take a light approach to the difficult subject, presenting both humorous and serious scenarios to illustrate why advance care planning is important.

One video explains the difference between hospice and palliative care, two services that are often discussed when serious health issues are at hand. Both services manage symptoms, but palliative care does so while seeking a cure, and hospice is an option only when a patient has months or weeks to live.

Duke patient advocate Tiffany Christensen, a member of the council, wrote and directed the videos, and understands firsthand the benefits of making advance care decisions. Born with cystic fibrosis, she has undergone two double-lung transplants.

“One of the things we really want people to understand is if you’re 18 years old, you need to start thinking about this,” Christensen says. “It’s not just about the documents. It’s about having the conversation.”

Taking Care of Business

Patients may download advance directive forms (PDF, 116 KB) on our site. Once you have talked with family members about your wishes, you need to have the forms notarized. Many banks and some physician offices can provide that service -- call to find out.

For patients in the hospital, Duke provides notaries who will come to the bedside or meet you in clinic. Health care providers, patient advocates, pastoral care representatives, or social workers can explain details and help you fill out the forms.

It’s also a good idea to discuss your choices -- before and after the fact if necessary -- with your health care provider. Once your decision is made and your paperwork finalized, your provider will keep copies of the forms on file.

It is important to continue to talk to loved ones about your advance care wishes from time to time. You should update your forms if there is a health status change, if one of your healthcare agents is no longer willing or able to represent you, or if it has been more than a year since you have reviewed the documents.

Additional Resources

The North Carolina Secretary of State offers an advance care directive registry. The registry enables health care providers to find directives if patients are unable to provide them -- for example, a serious illness or accident that takes place in another state.

Breakfast: Just What the Doctor Ordered

Thu, 12 Apr 2012 12:18:09 -0400

Why is breakfast important? Studies have shown that eating a healthy breakfast fuels your brain to improve focus, jump-starts metabolism for weight loss, increases energy levels, stabilizes mood, and helps keep you from overeating throughout the day.

We asked some of the busiest people around, Duke primary care providers, to tell us what they eat to get their day off to a healthy start.

Jason Troiano, MD

Practice Medical Director
Wake Forest Family Physicians

I am a big believer that fresh fruits, fresh vegetables, and whole grains are the cornerstone of a healthy diet and one of the best ways to prevent heart disease, strokes, and cancer. Every day for breakfast, I try to eat a bowl of high-fiber cereal with half a banana or some blueberries on top.

I recommend a cereal with 4 to 6 grams of fiber per serving on the label. Doing this along with aerobic exercise for 20 to 30 minutes several times a week is a great way to start a healthy lifestyle.

Do you ever skip breakfast or eat in the car? Never.

Leanne Owens, MHS, PA-C

Hillsborough Family Practice

A few years ago my priority was eating a quick breakfast rather than a healthy one. However, when my daughter began to eat table foods, my priority shifted.

Now we eat a quick and healthy breakfast together: one wholegrain vegetable muffin, a side of fruit, and low-fat yogurt. I make the muffins in advance, freeze them, and take them out the night before to thaw. They are ready to eat in the morning.

Do you ever skip breakfast or eat in the car? No.

Recipe for Vegetable Muffins

Here is my family recipe for vegetable muffins via my sister-in-law Meredith:

Ingredients

1 cup all-purpose flour
1 cup whole wheat flour
2 teaspoons ground cinnamon
1 teaspoon baking soda
1/4 teaspoon baking powder
1/4 teaspoon salt
1 cup sugar
1/2 cup applesauce and 1/4 cup canola oil
3 large eggs
1 teaspoon vanilla extract
3 cups grated vegetable of choice: zucchini, sweet potato, or carrot
1 cup chopped walnuts

Directions

Preheat oven to 350 degrees.
Sift first six ingredients into medium bowl. Beat sugar, applesauce, oil, eggs, and vanilla in large bowl.
Mix in vegetables.
Add dry ingredients and walnuts, and stir well.
Transfer batter to prepared muffin pan. Cook for 25 to 30 minutes, until a toothpick comes out clean.

Christopher Z. Rayala, MD

Duke Primary Care Morrisville

I eat a cup of high-protein, high-fiber cereal with a cup of skim milk. For me, this is the perfect breakfast.

The cereal I choose contains 10 grams of fiber, which supplies 40 percent of my daily fiber needs. With the milk, it’s just 230 calories and also contains 21 grams of protein, which helps keep me stay fuller longer. It is low in fat and sodium.

Sometimes I add blueberries, raspberries, or strawberries to make it more interesting.

Do you ever skip breakfast or eat in the car? Never have, never will.

Monica Barnes-Durity, MD

Duke Primary Care Morrisville

I choose breakfasts with a balance of protein, fiber, and healthy nutrients that are quick, easy to make, and less than 400 calories. I am always counting or “guesstimating” calories, as I too am weight-challenged and have size and fitness goals. I never leave home without breakfast.

I have a hot caffeinated beverage -- coffee or tea with ½ cup of soy or almond milk (50 calories) -- and one of the following options, which are all gluten-free and vegetarian.

Do you ever skip breakfast or eat in the car? Never skip; occasionally eat in the car.

Oatmeal with Options

My most-used recipe -- even my daughters can throw this together for me.

Start with 1/2 cup rolled oats (150 calories).
Add 1 cup hot water, or 1/2 cup water and 1/2 cup soy milk (50 calories).

Sometimes I’ll add one scoop of vanilla-flavored protein shake powder (100 calories).

Flavor options: five prunes (110 calories), 1/2 banana (52 calories), 1/2 apple (22 calories), cinnamon, or a spritz of vanilla extract

Texture options: 12 almonds (1/2 ounce, 82 calories) or 2 tablespoons of ground flaxseed (60 calories)

Quickie Quesadillas

Place one ultra-thin yellow corn tortilla (40 calories) in hot flat pan.
Add spinach leaves. Sometimes I zap these in the microwave with some garlic, onions, and other veggies, but with the time restrictions of a work morning, I usually just put a handful on the tortilla with a sprinkle of red pepper flakes or cayenne pepper powder.
Add cheese. I use whatever’s available and already shredded -- Mexican, pepper jack, or veggie mozzarella.
Fold and flip. Repeat this as needed to heat and cook the inside ingredients through, or at least melt the cheese.
Top with a tablespoon of salsa.

Breakfast on the Run

When there is no time and I’m heading to the car, I choose one of these options:

2 tablespoons of peanut butter (eat it right off the spoon, 200 calories)
24 almonds (1 ounce, 160 calories) and an apple (small Gala, 45 calories), banana (105 calories), or 1 cup blueberries (82 calories)

Overactive Bladder and Urinary Tract Infections: Gotta Go . . . and Go . . . and Go?

Thu, 12 Apr 2012 11:32:41 -0400

Overactive bladder and urinary tract infections have some similar symptoms, but it’s important to determine which problem you have and treat it properly.

Duke urologists Aaron Lentz, MD, and Charles Viviano, MD, PhD, answer our burning questions.

Aaron C. Lentz, MD

What’s the difference between overactive bladder and a urinary tract infection (UTI)?

Overactive bladder is defined as a sudden, compelling desire to urinate (known medically as urgency), with or without involuntary leakage, occurring more often than usual (known as frequency) during the day and night.

The symptoms of a urinary tract infection vary, but usually include painful urination, frequency or urgency, and pain occurring above the pubic bone. Bloody or bad-smelling urine are common. If a woman has even one of these symptoms, there’s a 50 percent chance that she has a UTI; with a combination of these symptoms, the odds are 90 percent.

Charles J. Viviano, MD, PhD

It’s important to differentiate between overactive bladder and UTI.

While they can have similar symptoms, the therapies to treat each are quite different. Incorrectly diagnosing the symptoms often leads to ineffective care and patient frustration.

Physicians diagnose patients with painful urination, frequency, and urgency based on their medical history, a physical examination, and a urine test.

What are the most common causes of UTIs? What causes them to become chronic?

There are a small number of bacterial pathogens, all well understood and treatable, that cause UTIs when they enter the urethra. For women, E. coli is the cause in 75 to 90 percent of cases. In men, E. coli and other enterobacteria are the most common causes.

Chronic recurrent UTIs can be caused by bacterial persistence, in which bacteria linger in the urinary tract and re-emerge after antibiotic use. They can also be recurring new infections from bacteria outside the urinary tract.

The distinction is important: if there’s an abnormality in the urinary tract that’s causing the bacterial persistence, correcting that abnormality usually cures the problem.

Women with reinfection often do not have an alterable urologic abnormality, and require long-term medical management. Reinfections in men are uncommon and may be associated with an underlying abnormality such as a narrow urethra.

The next step in therapy for chronic UTIs is intermittent or continuous low-dose antibiotic use. To prevent bacterial resistance, physicians might switch the antibiotic used.

Why is overactive bladder more prevalent in senior citizens?

At any age, continence depends on not only the health of your urinary tract, but also the presence of adequate mental capacity, mobility, dexterity, and other factors. All of these things can change, sometimes dramatically, during the aging process, which is why urinary incontinence is a major problem for the elderly.

It afflicts 15 to 30 percent of older people living at home, one-third of those in acute-care settings, and half of those in nursing homes.

The lower urinary tract changes with age, even in the absence of disease. In both sexes, the ability to postpone urinating declines, while the prevalence of involuntary bladder contractions increases, leading to more episodes of nighttime urination. Overactive bladder is the most common type of lower urinary tract dysfunction in incontinent senior citizens.

What can I do to prevent and treat overactive bladder?

Although there is no established strategy for preventing overactive bladder, there are some behavioral therapies that may improve bladder control. When started early, patients may not require additional treatment.

Conservative management for overactive bladder includes weight loss, quitting smoking, decreased use of caffeine, decreased intake of spicy food, decreased alcohol use, and changes in diet.

Lifestyle interventions include pelvic floor muscle training and bladder retraining. If the patient has urgency triggered by running water, “key in the door” syndrome (urgency upon arrival at home), getting up from a seated position, etc., then contracting the pelvic floor muscles prior to the activity may prevent the urge to urinate.

Bowel regularity is crucial because constipation makes bladder symptoms worse. Some patients may also benefit from a voiding schedule (urinating every hour, for instance) and gradually increasing the intervals between voids.

What can I do to prevent and treat recurrent UTIs?

There is no established method for preventing the development of chronic UTIs in someone who doesn’t already have that problem. In general, patients are advised to maintain a healthy weight and stay well hydrated.

Constipation may increase the risk of urinary tract infections. UTIs associated with sexual intercourse may benefit from a single dose of antibiotics after sex.

Postmenopausal women may benefit from a short course of topical estrogen if they suffer from vaginal dryness and irritation.

A lot of people ask whether cranberry supplements help prevent UTIs. There’s no real evidence that it works, but we don’t discourage it if the patient wants to try. Factors that are often cited but are not documented sources of recurrent infection include hygiene, frequency and timing of urination, wiping patterns, use of hot tubs, and type of undergarments.

Aaron Lentz, MD, and Charles Viviano, MD, PhD, treat patients at Duke Urology of Raleigh, located on the campus of Duke Raleigh Hospital. They offer advanced care for everyday urological concerns and complex conditions.

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Who does this type of research, and why is it important?

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What are some other examples of translational research taking place at Duke?

How does the Duke Cancer Institute impact translational research?

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Tough Topic, Gentle Touch

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Additional Resources

Breakfast: Just What the Doctor Ordered

Jason Troiano, MD

Leanne Owens, MHS, PA-C

Recipe for Vegetable Muffins

Ingredients

Directions

Christopher Z. Rayala, MD

Monica Barnes-Durity, MD

Oatmeal with Options

Quickie Quesadillas

Breakfast on the Run

Overactive Bladder and Urinary Tract Infections: Gotta Go . . . and Go . . . and Go?

What’s the difference between overactive bladder and a urinary tract infection (UTI)?

What are the most common causes of UTIs? What causes them to become chronic?

Why is overactive bladder more prevalent in senior citizens?

What can I do to prevent and treat overactive bladder?

What can I do to prevent and treat recurrent UTIs?

Who does this type of research, and why is  it important? 

How is the Duke Cancer Institute involved  in translational research? 

What are some other examples of translational research taking place at Duke? 

How does the Duke Cancer Institute impact translational research? 