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The 4 Pillars: Foundation for Care

The Duke Cancer Institute
For more than 75 years, the cancer programs of Duke University Medical Center in Durham, North Carolina, have been at the forefront of research and patient care, with more than 800 researchers, physicians, and clinical staff serving nearly 6000 new patients each year from the United States and abroad. In 1972, Duke’s cancer program was designated as one of the nation’s 8 original comprehensive cancer centers by the National Cancer Institute (NCI), and is today one of only 40 such centers nationwide. Ranked as one of the top cancer hospitals in the United States for nearly 20 years by US News & World Report, Duke attracts the best cancer clinicians and scientists from across the country and around the world, and maintains clinical and research partnerships throughout the United States, as well as in India, China, and Singapore.

Those familiar with Duke’s stellar reputation are well aware of the accolades, honors, and achievements credited to its cancer researchers, clinicians, and academicians, but few milestones have inspired the kind of excitement being generated by the November 2010 formation of the new Duke Cancer Institute (DCI). The DCI brings together clinicians, researchers, and educators from across Duke’s hospital, medical school, and health system under a single administrative umbrella. This, in turn, intimately links patient care, research, and medical training in a unified pursuit. A new cancer center building is scheduled to open in February 2012, and a new leader, Michael B. Kastan, MD, PhD, was named to the Institute’s helm in May.

Already, DCI promises to have a profound impact on both cancer research and patient care. By providing unprecedented and unique opportunities for teamwork between Duke’s scientists and caregivers, the reorganization aims to more quickly translate novel therapies from bench to bedside and to optimize all aspectsof patient care. The most important of its goals is to provide patients with a less tangible but equally critical tool in the battle against their cancers: hope. The Preston Robert Tisch Brain Tumor Center and the Duke Prostate Center (DPC) serve as 2 prime examples.

The Preston Robert Tisch Brain Tumor Center

Using the words “brain cancer” and “hope” in the same sentence may seem counterintuitive, but neurooncologist Henry S. Friedman, MD, co-director of the Preston Robert Tisch Brain Tumor Center, does so routinely and unabashedly.

“Everything we do for our patients is doomed to fail unless we’re able to offer them hope,” he said, “and the formation of the new Institute is helping to translate ‘hope’ from nebulous concept to concrete reality.”

Established in 1937 as one of the nation’s first brain tumor research and clinical programs, the Duke program was renamed the Preston Robert Tisch Brain Tumor Center in 2005 in recognition of a $10 million gift from the Tisch family. Today, the Center is one of the world’s leading adult and pediatric neuro-oncology centers, and has received the NCI’s highest rating of “outstanding” for each of the last 10 years.

The Center’s 250-plus scientists, physicians, nurses, and other staff have at their disposal the resources of a leading research hub at the cutting edge of translational medicine, providing them with the means to offer patients the latest treatment advances, as well as access to a range of clinical trials, including those examining the efficacy of stem cell therapy and cancer vaccines. Equally important is the Center’s reputation for providing the compassionate support needed by patients and their families living with brain and spinal cancers.

“The philosophy of hope has always formed the foundation for the care we provide at the Center,” said Friedman, who considers brain and spinal cancers curable until proved otherwise. “This is a guiding principle that necessarily comes from the top down, and is continually nourished and sustained among veteran staff and new hires.” He went on to note that, even for patients living with these most feared of all malignancies, the brain tumor center’s integral role in the DCI fosters hope with an exchange of ideas and research findings that will speed the pace of discovery.

Friedman cited glioblastoma, the most common malignant brain tumor in adults, as an example. “While most people would tend to use the word ‘hopeless’ when referring to this diagnosis, patients with glioblastoma don’t necessarily die, and many are living longer than ever before,” he said. This point is borne out by NCI data showing that, compared with 1985, when fewer than 25% of patients lived 5 years with brain cancer, the 5-year survival rate now hovers at 35%, and more patients are surviving 10 and even 15 years past their initial diagnosis. (See http://seer.cancer.gov/faststats/selections.php?#Output.)

“Even those who ultimately succumb to their disease reap the benefits of enhanced quality of life,” Friedman said. “Hope is self-sustaining.” Friedman is, however, careful to differentiate between false hope and the hope given to patients at the Tisch Center. “We’re not talking about some abstract concept based on hand-holding and words of encouragement,” he stressed. “Real hope requires that we deliver substance.”

The 4 Pillars

According to Friedman, “substantive hope” is one of the “4 pillars” that form the foundation for the care provided to the 900 to 1000 newly diagnosed patients seen each year at the Tisch Center. The other 3 core missions are basic research, clinical research, and exemplary patient care.

While the evaluation of a variety of therapeutic approaches is nothing new in the field of neuro-oncology, the care teams at the Tisch Center take this approach a step further by assessing the feasibility of multiple treatment strategies attempted not in sequence but all at once. “Rather than trying one treatment and then another when the first fails, we look at a comprehensive approach to treatment for each patient that may involve the use of multiple therapies from the onset,” he explained. Such an approach might involve approved therapies, along with those under investigation through clinical trials, including vaccines and targeted therapies involving monoclonal antibodies and anti-angiogenesis agents. The Center’s researchers also are involved in comprehensive genetic analyses aimed at identifying tumor aberrations for targeting by these novel agents. “What the DCI does is foster a venue for the free flow of information among our scientists and clinicians,” Friedman said. “There’s little doubt that our patients will be the primary beneficiaries.”

The Duke Prostate Center

Also receiving a new infusion of hope by virtue of DCI’s reorganization are the patients of Duke’s genitourinary cancer program, which has long been a leader among the specialties of Duke’s cancer program.

Each year, Duke clinicians treat 700 to 800 newly diagnosed prostate cancer patients from around the world, and the number of those seeking treatment and/or second opinions at the DPC continues to grow. One favorable “side effect” of this growth is the recent influx of more than a dozen top medical oncologists, urologists, and radiation oncologists into the Duke program.

From the beginning, patients have had the opportunity to interact with a variety of specialists at the prostate cancer center, including urologists, medical oncologists, radiation oncologists, and support staff. But with the Center’s scheduled move into the new clinical building in February, patients will have access to all prostate specialists under one roof in a facility that also will house many of the Center’s scientists.

Urologist and medical oncologist Daniel J. George, MD, has been the director of the section of genitourinary medical oncology at Duke University Medical Center since 2003, and was recently appointed Duke’s medical director of cancer clinical research.

“Our genitourinary cancer program serves as an excellent example of late stage, the disease still appears to be testosterone-dependent. “This relatively new understanding has moved the field toward targeted therapies even in castrate-resistant disease,” he explained, noting that ongoing research in areas such as upregulation of androgen and the use of copper-dependent agents to create conditional lethality is especially exciting. Echoing George’s enthusiasm is Stephen J. Freedland, MD, Duke’s vice chief of urology research and associate director of genitourinary cancer clinical research. Freedland views the reorganization provided by the new Institute as a natural next step in the evolution of cancer care and research. “The reorganization removes some significant barriers and allows us to take full advantage of our colleagues’ areas of strength and expertise,” he said. Freedland noted, for example, that clinical trials have historically tended to be a strength of medical oncologists, while urologists tended to excel at creating databases. The shared expertise made possible by the DCI will give Freedland access to the best of both worlds in his planned clinical trials to examine the effects of diet and lifestyle modifications on the progression of prostate cancer. He noted that it also will prove beneficial in his ongoing trial of the use of hormonal therapy in prostate cancer and a low-sugar diet for resultant diabetes. Some clinics have already been how and why the DCI will set Duke apart from other cancer centers,” said George. “As successful as our cancer programs have been, the separation between research and clinical care has been somewhat limiting, and the new Institute is providing the means and venue for true continuity with respect to both research and patient care.”

In what he described as a paradigm shift, George explained that the historically department based faculty has now become program based, with all resources pooled under the DCI umbrella. Also unique is the geographic proximity of the undergraduate campus to the medical center, facilitating collaboration between medical oncology, radiation oncology, pharmacology, and those from departments such as chemical engineering.

“It’s an exciting time for genitourinary cancer researchers,” said George, whose own research includes trials of drugs that inhibit blood flow to tumors and whose areas of interest include the study of blood flow in renal cell carcinoma and growth factors as prognostic markers and molecular targets in prostate cancer.

“We’re now making very real strides in our understanding of the biology of these cancers, which, in turn, allows us to make some very meaningful progress,” he said. George cited endstage metastatic prostate cancer as a prime example, noting that, even in this late stage, the disease still appears to be testosterone-dependent. “This relatively new understanding has moved the field toward targeted therapies even in castrate-resistant disease,” he explained, noting that ongoing research in areas such as upregulation of androgen and the use of copper-dependent agents to create conditional lethality is especially  exciting.

Echoing George’s enthusiasm is Stephen J. Freedland, MD, Duke’s vice chief of urology research and associate director of genitourinary cancer clinical research. Freedland views the reorganization provided by the new Institute as a natural next step in the evolution of cancer care and research.

 
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