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.

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.

GERD, Barrett’s Esophagus and the Risk for Esophageal Cancer

**By Donald E. Low, MD, FACS**


Kathi Brunson and her husband Tom

Ellensburg resident Kathleen (Kathi) Brunson is lucky and she knows it. Her good fortune – namely in the form of better health – is something she’s thankful for every day.

The 75-year-old Japanese-American, who was a legal secretary in Ellensburg for almost 30 years, was diagnosed with advanced esophageal cancer in 2006. Kathi’s primary care physician insisted on further testing after Kathi mentioned trouble swallowing during an annual checkup.

That simple mention eventually lead to the discovery of a cancerous mass in her esophagus and a referral to Virginia Mason. After many weeks of chemotherapy and radiation at Virginia Mason Memorial’s North Star Lodge in Yakima, I performed Mrs. Brunson’s surgery in Seattle.

Now, 10 years later, she is healthy and cherishing every minute with her husband, two married daughters and four grandchildren.

Although Mrs. Brunson periodically wonders what might have caused her cancer, especially since she didn’t have any of the typical risk factors and has eaten a vegetable-rich diet most of her life, she tells people all the time to listen to their bodies and be their own health advocates.

As Mrs. Brunson can attest, education, awareness and being proactive are critical to helping put people in the best position to successfully battle cancer.

Cancer screenings

If you’ve ever been affected by a cancer diagnosis, a screening exam is common.

Cancer screening exams are important medical tests performed when people are at risk but don’t have symptoms. They help detect cancer at its earliest stage, when the chances for successful treatment are highest. Unfortunately, to date no standardized screening tests have been shown to improve esophageal cancer outcomes.

Esophageal cancer risk factors

Anything that increases your chance of getting esophageal cancer is a risk factor.

If you experience frequent heartburn, talk with your doctor about tests that may help find esophageal cancer early. Long-term heartburn or reflux is a factor in half of esophageal cancers.

Other risk factors for esophageal cancer include:

  • Long-term history of smoking
  • History of other squamous cell cancers related to tobacco use
  • Drinking too much alcohol, especially if you smoke
  • Age: Most esophageal cancers occur in people over 55
  • Gender: Men are three times more likely to develop esophageal cancer
  • Achalasia: A disease in which the muscle at the bottom of the esophagus fails to open and move food into the stomach
  • Tylosis: A rare, inherited disorder that causes excess skin to grow on the soles of the feet and palms. It has an almost 100 percent chance of developing into esophageal cancer
  • Esophageal webs: Flaps of tissue that protrude into the esophagus, making swallowing difficult
  • Lye ingestion or being around dry-cleaning chemicals
  • Diet and weight: Risk is higher if you’re overweight, tend to overeat or don’t eat a healthy diet

Not everyone with risk factors gets esophageal cancer. However, if you have risk factors, you should discuss them with your physician.

At risk for esophageal cancer?

There are two main types of esophageal cancer: squamous cell cancer and adenocarcinoma of the esophagus.

Squamous cell cancer occurs most often in African Americans, as well as people who smoke cigarettes and drink alcohol excessively. Fortunately, this type of cancer is not increasing in frequency.

Adenocarcinoma of the esophagus occurs most commonly in Caucasians, as well as people with gastroesophageal reflux disease (GERD). Unfortunately, this cancer is increasing in frequency.

The most common symptom of GERD is heartburn, a condition that 20 percent of American adults experience at least twice a week. Although these individuals are at increased risk of developing esophageal cancer, most will never develop it. But in a few patients with GERD (estimated at 10 to 15 percent), a change in the esophageal lining develops, which is a condition called Barrett’s esophagus. Experts believe most cases of adenocarcinoma of the esophagus begin in Barrett’s tissue.

It is very important for everyone who has had a continuing issue with dysphagia, which is the impression of food sticking in the chest, to see their physician and have it looked at immediately.

What is Barrett’s esophagus?

Barrett’s esophagus is a condition where the esophageal lining changes, becoming similar to tissue that lines the intestine. A complication of GERD, Barrett’s is more likely to occur in patients who either first experienced GERD at a young age or have had symptoms for a while. The frequency and or severity of GERD does not affect the likelihood that Barrett’s may have formed. Dysplasia, a precancerous change in the tissue, can develop in any Barrett’s tissue. Barrett’s tissue is visible during endoscopy, although a diagnosis by endoscopic appearance alone is not enough. A definitive diagnosis of Barrett’s esophagus requires confirmation through a biopsy.

How do you test for Barrett’s esophagus?

A gastroenterologist will first perform an upper endoscopy using a thin, flexible scope with a light and camera on the tip to diagnose Barrett’s esophagus. Barrett’s tissue has a different appearance than the normal lining of the esophagus and is visible during endoscopy. Although this exam is very accurate, your doctor will take biopsies from the esophagus to confirm the diagnosis as well as look for the precancerous change of dysplasia that can’t be seen with the endoscopic appearance alone. Taking biopsies from the esophagus through an endoscope only slightly lengthens the procedure time, doesn’t cause discomfort and rarely creates complications. Your doctor can usually tell you the results of your endoscopy after the procedure, but you will have to wait a few days for biopsy results.

Who should be screened?

Barrett’s esophagus is twice as common in men as women. It tends to occur in middle-aged Caucasian men who have had heartburn for many years. There is no agreement among experts on who should be screened. Even in patients with heartburn, Barrett’s esophagus is uncommon and esophageal cancer is very rare. One recommendation is to screen patients older than 50 who have had significant heartburn or required regular medication use to control heartburn for several years. If the first screening for Barrett’s tissue is negative, there is no need to repeat it.

How is Barrett’s esophagus treated?

Medicines and or surgery can effectively control the symptoms of GERD. However, neither medications nor surgery can reverse the presence of Barrett’s esophagus or eliminate the risk of cancer. There are some experimental treatments through which the Barrett’s tissue can be destroyed using the endoscope. These treatments are becoming more common, but should only be considered in patients with Barrett’s, dysplasia or the earliest form of esophageal cancer.

What is dysplasia?

Dysplasia is a precancerous condition that doctors can only diagnose by examining biopsy specimens under a microscope. Doctors subdivide the condition into high-grade, low-grade or indefinite. If dysplasia is found on your biopsy, your doctor might recommend more frequent endoscopies, attempts to destroy the Barrett’s tissue, or esophageal surgery. Your doctor will recommend an option based on the degree of the dysplasia and your overall medical condition.

If I have Barrett’s esophagus, how often should I have an endoscopy to check for dysplasia?

The risk of esophageal cancer in patients with Barrett’s esophagus is quite low, about 0.5 percent per year or one out of 200. For this reason, a Barrett’s esophagus diagnosis should not be reason for alarm. It is, however, reason for periodic endoscopies. If your initial biopsies do not show dysplasia, endoscopy with biopsy should be repeated about every three years. If your biopsy shows dysplasia, your doctor will make additional recommendations.

A version of this article was originally posted on LocalHealthGuide.com

Donald E. Low, MD, FACS, is board certified in General and Thoracic Surgery. He practices at Virginia Mason Hospital and Seattle Medical Center.  His specialties include esophageal cancer, thoracic surgery, esophageal diseases, esophageal surgery, gastrointestinal cancer, lung cancer, lung surgery, and minimally invasive surgery.