Virginia Mason to Study Breath Test for Detecting Esophageal Cancer

Research is beginning at Virginia Mason Medical Center that will evaluate the accuracy of a breath test for detecting esophageal cancer, one of the fastest growing and deadliest cancers in the United States.

The project, supported by a grant from the Salgi Esophageal Cancer Research Foundation, is led by Donald Low, MD, who specializes in esophageal and thoracic surgery at Virginia Mason, and George Hanna, PhD, of St. Mary’s Hospital in London (Imperial College Healthcare), who is the co-investigator.

At Virginia Mason, the project will involve as many as 50 patients over the next 12 to 18 months. The research will attempt to build on findings from recent research into a potential breath test for esophageal cancer conducted in England. See article in JAMA Oncology.

The ultimate goal is to develop a noninvasive test for the detection of esophageal cancer that is based on the unique signature of volatile organic compounds in exhaled breath.

“There are currently no standard screenings for the early detection of esophageal cancer, and symptoms often present only after the illness is advanced and difficult to treat,” Dr. Low said. “We hope to change this. Research in London demonstrated the potential for breath analysis to provide an indication when early esophageal cancer has occurred. The purpose of our study is to assess the diagnostic accuracy of a breath test.”

Virginia Mason researchers will examine the reliability of such a test “longitudinally,” Dr. Low added, explaining that patients enrolled in the study will provide sputum and urine samples, in addition to exhaled breaths, that will be evaluated for common markers at three separate points in their treatment journey. The ultimate goal is to develop a noninvasive test for the detection of esophageal cancer that is based on the unique signature of volatile organic compounds in exhaled breath.

In 2019, an estimated 16,000 people will die from esophageal cancer in the United States, while less than 20 percent of those diagnosed with the disease will survive more than five years, according to the National Cancer Institute.

Gastroesophageal reflux disease (GERD), also called acid reflux disease and heartburn, can lead to Barrett’s Esophagus, a primary risk factor for esophageal cancer.

“One of the reasons for conducting research is that you never know what you will discover,” said Dr. Low. “It’s exciting to imagine a day, not far in the future, when a person will breathe into a special device that can provide reliable information, based on the breath, indicating whether the individual has early-stage esophageal cancer. This would be a marvelous advancement for medicine and patients. My colleagues and I are proud to be involved in the assessment of this new diagnostic approach.”

Low,Donald02colorDonald Low, MD, FACS, is Program Director of the Esophageal Center of Excellence, providing comprehensive, multidisciplinary care for a range of esophageal and gastrointestinal issues. If you have questions or are experiencing symptoms, please call (206) 223-2319.

Worth the Distance: Advanced Cancer Treatment Helps Alaska Man After Just One Infusion

**By Hagen F. Kennecke, MD, MHA, FRCPC

The day after Christmas in 2016 brought unwelcome news for Wasilla, AK resident Josh McCool.

McCool, then 26, was diagnosed with a rare tumor of his adrenal gland, called a pheochromocytoma (fee-o-kroe-moe-sy-TOE-muh). But after surgery to remove the tumor, a type that can cause serious complications but is rarely cancerous, McCool’s symptoms returned and got much worse.

“My resting heart rate was very elevated,” remembers McCool. “I was super weak, unable to play with my kids, and spending 16 to 18 hours a day in bed. On top of that, I lost more than 100 pounds over six months. I would be out of breath just walking from our couch to the kitchen.”

A Rare Cancer 

McCool’s pheochromocytoma was a type of malignant tumor known as a neuroendocrine tumor, or NET. There are many types of NETs, some which make abnormally high amounts of hormones that cause many different symptoms. After traveling to the Seattle Cancer Care Alliance and undergoing extensive evaluation, McCool was referred to the Neuroendocrine Tumor program at Virginia Mason Medical Center.

That’s when I first met McCool, who had become very weak and sometimes needed a wheelchair. He was in significant pain and his cancer was secreting adrenaline, which was causing even more symptoms. To help target his treatment we used a specialized PET-CT scan, called NETSPOT®, which identifies hormone receptors on cancer cells.

With the cell receptors identified, McCool became a candidate for an advanced treatment known as Peptide Receptor Radionuclide Therapy (PRRT) with a treatment called Lutathera®. In PRRT, a cell-targeting protein, or peptide, is combined with a small amount of radioactive material. When injected in the blood stream, this new substance, called a radiopeptide, binds to NET cells, delivering a high dose of targeted radiation.

Josh Before and After Treatment

Immediate Results

Amazingly, just one week after his first treatment, McCool noticed his symptoms were improving. A better appetite was followed by markedly more energy, increased activity and a significant decrease in his back pain. The targeted nature of PRRT — binding to a protein only on the cancer cells — greatly minimized side effects.

A total of four treatments were needed, once every two months. Since PRRT is not available in Alaska, McCool arranged travel to Virginia Mason. After only his second infusion, McCool was completely off pain medications, had gained weight and was able to play with his two young sons.

A New Beginning

Josh-McCool_Shannon-and-sonsDespite all the challenges of therapy, McCool feels very lucky. “Getting the green light to move ahead with the treatment was like winning the lottery,” says McCool. “It has definitely been a character building experience and one I couldn’t have gotten through without the amazing support system of family and friends that I’ve been blessed with all along the way.”

McCool finished his treatment this month and is planning a trip to Disneyland with his family next year.

All of us on the Neuroendocrine Tumor Program team who took care of Josh McCool take great inspiration from the remarkable improvement in his health. While PRRT is not a cure, the treatment has the potential for adding years to an active and fulfilling life.

Hagen F. Kennecke, MD, MHA, FRCPC
Hagen F. Kennecke, MD, MHA, FRCPC, has advanced training in oncology and specializes in neuroendocrine tumors and colorectal cancers. He is director of the Cancer Institute at Virginia Mason. Dr. Kennecke practices at Virginia Mason Hospital and Seattle Medical Center.

Prostate Cancer Curable with Early Detection

Some people dread their annual medical examinations, but not Doug Holbrook. He knows his annual executive physical saved his life. The doctor administering the first physical gave Doug, who was 45 at the time, the option of skipping the prostate screening because of his age. Doug, however, thought it made sense to take advantage of every test offered. This first test established a baseline measure of his prostate-specific antigen (PSA level).


Doug Holbrook

The prostate is a small gland located just below the bladder. The PSA test measures the level of PSA proteins in the blood that are produced by the prostate. For this test, a blood sample is sent to a laboratory for analysis. The blood level of PSA is often elevated in men with prostate cancer. In addition to prostate cancer, a number of benign (noncancerous) conditions can cause also a man’s PSA level to rise including inflammation and enlargement of the prostate.

Most doctors considered PSA levels of 4.0 ng/mL and lower as normal. In general, however, the higher the PSA level, the more likely it is that patient has prostate cancer. A continuous rise in the PSA level over time may also be a sign of prostate cancer, which is what Doug experienced.

Over the next year and a half his PSA levels increased. A biopsy of his prostate confirmed he did have cancer.

“We routinely cure prostate cancer when it is detected early,” says John M. Corman, MD, urologist and medical director of Virginia Mason’s Perioperative Unit. “That is why it is important for men over age 50 to discuss PSA-based prostate cancer screening with their primary providers and, when appropriate, to have yearly evaluations to rule out the disease.” Screenings include the PSA blood test and a physical examination.

After hearing his diagnosis, Doug was presented with several treatment options, including watch and wait, focused radiation or laparoscopic radical prostatectomy (LRP), a minimally invasive technique used to remove the prostate.

Doug chose the prostatectomy. “For me the choice was simple, as soon as I knew it was inside me, I wanted it out.” Six months after the surgery, he was symptom free and back to his busy life, traveling internationally for his company, hiking, fishing, snowmobiling and walking his two Labrador Retrievers. He continues to live a healthy life and is sure to make time for his annual physical.

A version of this story also appears in the Virginia Mason Health System 2018 Annual Report. 

Exciting Developments for Pancreatic Cancer Care

**By Flavio G. Rocha, MD**

After successful treatment for pancreatic cancer, one of our patients shared her story. Life after cancer is not normal, she said, it’s better than that. She talked of being inspired by the dedication of the Virginia Mason team. As a member of this team, a cancer surgeon and a clinical researcher, I am inspired by the progress we and other organizations are making toward better treatments for this disease. Working together to discover new therapies and the potential for early detection, the future of treating pancreatic cancer has never felt more hopeful.

Today Virginia Mason sees almost a third of all pancreatic cancer patients in Washington state, with decades of experience delivering care as a multidisciplinary team. This collaboration across specialties – along with advances in imaging, surgical techniques, specialized treatment and safety protocols – contributes to a doubling of the overall survival of our patients compared to the national average, as reported by the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program.

researchVirginia Mason is also invested in world-renowned medical research with Benaroya Research Institute (BRI), offering patients access to clinical trials investigating new therapies for all stages of pancreatic cancer. As a BRI affiliate investigator, I see a new wave of disease-fighting possibilities ahead, based on the latest research involving cancer cell microbiology, genetic testing and immunotherapy.

Reach Goal: Early Detection

Despite improvements in treatment, an estimated 46,000 people in the U.S. will die of pancreatic cancer this year. That’s because 90 percent of cases are diagnosed in later stages, when the cancer has already spread to other tissues or organs or requires preoperative therapy to reduce tumors. Virginia Mason, in partnership with BRI and other research collaboratives, is focused on looking inside the pancreatic cancer cell to identify biomarkers that signal a precancerous condition.

A specific protein, for example, was found in a clinical trial to be significantly elevated in the pancreatic fluid of patients known to have premalignant lesions. These results suggest that testing the fluid for this biomarker could detect disease in patients at increased risk, before becoming pancreatic cancer. Other research around early detection focuses on developing special blood tests, diagnostic imaging and other screening tools to find disease at its earliest stages.

Hereditary Cancer Testing

In July 2018, the National Comprehensive Cancer Network (NCCN) issued a new guideline that all individuals with a diagnosis of pancreatic cancer must meet criteria for hereditary cancer testing. Studies suggest up to 10 percent of pancreatic cancer is caused by an inherited mutation in BRCA1 or BRCA2, the so-called breast cancer genes. Other genetic mutations have been linked to an increased risk of pancreatic cancer as well.

Is there a benefit in genetic testing if the patient already has pancreatic cancer? Yes, for two reasons:

  • Knowing about an inherited genetic mutation may help direct treatment decisions. BRCA-associated cancers, for example, are known to respond to certain treatments, including specific types of chemotherapy. This concept of “personalized medicine” is expanding through clinical trials of other agents that target cancers linked to genetic mutations.
  • Identifying a mutation can be valuable knowledge for family members, who can choose to be tested and learn if they are at higher risk for developing certain cancers. That’s because the same mutation that is linked to pancreatic cancer is also associated with breast, ovarian and other cancers. Family members who test positive can engage in screening or risk-reducing strategies for other forms of cancer, as available.

Boosting the Body’s Immune System

Leveraging the power of the body’s own immune system to fight cancer is the science behind immunotherapy, variations of which are already prescribed by oncologists to treat a variety of cancers. While success has been limited using immunotherapies in the treatment of pancreatic cancer, ongoing clinical trials are testing multiple forms of the therapy, including pancreatic cancer vaccines (designed to “program” the immune system to attack cancer cells), and immune checkpoint inhibitors (shown to reactivate immune cells shut down by cancer cells). Other forms of immunotherapy utilize modified viruses to infect tumor cells, or modifications of the body’s own cells to disrupt cancerous activity.

The Future of Research is Now

Virginia Mason is one of 12 clinical trial sites selected nationwide by Precision Promise, the Pancreatic Cancer Action Network’s groundbreaking initiative to improve patient outcomes and double the pancreatic cancer survival rate by 2020. Starting this year, patients will be able to enroll in Precision Promise through the participating sites, accessing trials of multiple novel therapies alongside standard care approaches.

Through Precision Promise, clinical outcomes data will be continuously tracked and analyzed, accelerating findings that can be shared across the trial sites. Analysis methods, including the use of genomic data, will be matched to patients’ responses to therapy to quickly identify effective treatment options. As breakthroughs emerge, Precision Promise will adapt clinical programs to help get successful therapies out to patients faster than traditional research models.

What Keeps Us Going? Our Patients

The pancreatic cancer survivor who shared her story described the joy of seeing her daughter graduate, and teaching her son how to drive. As physicians we are privileged to not only treat disease with our best skills and knowledge, but to nurture hope in our patients that they will return to the lives and people they love. We have seen the pancreatic cancer survival rate increase 3 percent during the last three years, and momentum is building. The time for changing everything we know about diagnosing and treating this disease starts now.

Flavio Rocha, MD
Flavio G. Rocha, MD, has advanced training in surgical oncology and specializes in liver, biliary tract and pancreatic cancer. He is director of research in the Digestive Disease Institute at Virginia Mason and an affiliate investigator at Benaroya Research Institute. Dr. Rocha practices at Virginia Mason Hospital and Seattle Medical Center.

When Colon Cancer Spreads: Advanced Treatments Help People Live Longer, Better

**By Flavio G. Rocha, MD**

Cancer that starts in the colon can sometimes spread to other parts of your body, including the liver. Another name for it is metastatic, or stage IV, colon cancer.

Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. The American Cancer Society estimated that in 2016 more than 95,000 new cases would be diagnosed, and it was expected to cause more than 49,000 deaths last year.


As with many malignancies, symptoms vary depending on tumor size and where it has spread in your body. Some people with colon cancer that has spread to the liver don’t 3D human male x-ray digestive system.have symptoms. In other cases, they can include:

  • Bloody stool
  • Abdominal pain
  • Belly swelling
  • Feeling sick and tired
  • Weight loss


Your doctor might find that the disease has spread to your liver when he or she first diagnoses you. Or, after you’ve been treated, the colon cancer can come back and spread to your liver.

It is normal to worry when you have cancer that has spread. But treatment can make a real difference with symptoms, quality of life and longevity.

Your physician will help determine if you need surgery, chemotherapy, radiation or other liver-focused therapy. Doctors may be able to remove or shrink the tumor. Afterward, you’ll need to keep up with your doctor visits to stay symptom-free.

To determine location and size of the cancer, your doctor may order one or more imaging tests, including:

  • CT (computed tomography) – Powerful X-ray that makes detailed pictures of the inside of your body
  • MRI (magnetic resonance imaging) – Powerful magnets and radio waves that create pictures of organs and internal structures
  • PET (positron emission tomography) – Uses radioactive particles, or tracers, to find disease inside the body
  • Liver biopsy – Removing a tiny sample of the liver to test it
  • Colonoscopy – Visual inspection inside the colon using a camera-enabled scope

Being your own best health advocate

In today’s health care environment, most people understand that patients – along with their opinions and decisions – play an important role in the delivery of care. By advocating for themselves and getting involved in decision making, they can reap numerous benefits.

That is why I tell patients who are diagnosed with cancer that they should ask a lot of questions of their physician, such as:

  • What treatment or treatments will work best for me? What is involved with each?
  • How long will I need treatment?
  • What is my outlook?
  • What problems or side effects could I have? How will they be managed?
  • Should I consider participating in a clinical trial? If so, can you recommend one?
  • Could I benefit from a second opinion? If so, will you recommend another physician to get one from?
  • How often should I see you for follow-up appointments?

Treatment options

Even if the malignancy has spread to a person’s liver, the tumor is still made up of colon cancer cells. For that reason, your doctor will treat it like colon cancer, not liver cancer.

You may get one or more types of treatment. While the mainstay of treatment is chemotherapy, the only potential curative option for colon cancer that has spread to the liver is surgery, when possible.

Thanks to medical advances, there are numerous options for treating liver metastases either alone or in combination.

The innovative techniques described below allow surgeons to remove or “resect” multiple tumors in both lobes of the liver based on the liver’s ability to regenerate. The liver is a unique organ in that it can regrow after surgery, a property called “hypertrophy.” Surgeons can safely remove up to 80 percent of the liver and expect full regeneration in six to eight weeks as long as a patient doesn’t have substantial underlying liver disease, such as cirrhosis or chemotherapy-related liver injury. This is why it’s important to see both a surgical – and medical – oncologist prior to starting any therapy.

  • Parenchymal-sparing surgery – This surgical approach includes resection of individual liver segments (there are eight) performed alone or in combination with ablative therapies, where heat is used to destroy a tumor. Advantages of this strategy include removing less normal liver, which results in a quicker recovery and better chances for future resections, if necessary.
  • Portal vein embolization – This procedure induces regrowth on one side of the liver in advance of a planned resection on the other side. To be suitable, a patient must have enough functional liver remaining after the operation. However, the body requires that a minimum amount of liver remain (liver reserve) to support regrowth. If the liver reserve can’t support regrowth, surgeons may use portal vein embolization to jump start growth before surgery.
  • Two-stage hepatectomy – In this approach, tumors on one side of the liver are removed followed by tumors on the other side after a period of liver regeneration, which is usually on the heels of a portal vein embolization.
  • Microwave or radiofrequency ablation – In this approach, microwaves or an electric current are transmitted into the tumor through a thin needle or probe to heat and destroy liver tumors without removing them. It is used in patients with a few small tumors when surgery isn’t a good option.
  • Laparoscopic hepatectomy – This approach, which is a viable alternative to traditional resection, uses a laparoscope – a viewing tube with a small camera – to perform minimally invasive surgery through small incisions. Advantages can include less surgical stress, early discharge from the hospital, and rapid return to a normal diet and activity.

Other non-surgical treatments include:

  • Chemotherapy
  • Radiation (e.g., external beam radiation, radioembolization and brachytherapy)
  • Targeted therapies, also called “biologics”
  • Immunotherapy (prevention or treatment of disease with substances that stimulate immune response)

Perspective and promise

It is important to remember that every patient’s case is unique. Although these treatments may not cure your cancer, the goal is to help you live a longer, better life.

Researchers around the world are also involved in clinical trials looking for new, innovative ways to treat colon cancer that has spread. These trials test new drugs to see if they’re safe and effective. Clinical trials are often a good way for people to try new medicine that isn’t available to everyone. Your doctor can tell you if one of these research opportunities might be a good fit.

Taking care of yourself

Cancer patients go through a lot when battling a malignancy. During treatment, it’s especially important to rest, exercise, manage stress and eat well. During this trying time, it’s also important to get emotional support. Family, friends, social workers and therapists can be invaluable.


Treatments for colon cancer that has spread to the liver have greatly improved over the last quarter century. I encourage all my patients to take solace in the fact that people with this cancer are surviving longer than ever.

Dr. Flavio RochaA version of this article originally appeared in Seattle’s LocalHealthGuide. Flavio G. Rocha, MD, has advanced training in surgical oncology and specializes in liver, biliary tract and pancreatic cancer. He is director of research in the Digestive Disease Institute at Virginia Mason and an affiliate investigator at Benaroya Research Institute. Dr. Rocha practices at Virginia Mason Hospital and Seattle Medical Center (206-341-1904).