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 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 deter- mined 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
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.
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 chemo- therapy for the treatment of brain tumors. 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.
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. 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.
“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 clini- cians 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 multi-disciplinary approach, as well. “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.”
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.”
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 prog- ress 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 multi- disciplinary 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. “Sore mouth, loss of appetite, and terrible nausea.
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. “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.
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.
“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.”