A tradeoff of our overall life expectancy increasing may be that the odds of developing an illness over the years start to add up. Medical teams that serve New Jersey have a relatively smaller geography to cover, but the concentration of population means they see a high rate of cancer patients. Serving this segment of healthcare requires some dynamic approaches that continue to be refined to meet the evolving needs of cancer patients.
Despite New Jersey’s size, the local population density and other factors has put the state in the top 10 for cancer incidences, says Gopal Desai, chair of radiation oncology at Saint Peter’s University Hospital. “The state sees almost 470 cases per 100,000 people,” he says. Breast, lung and prostate cancers are the most common occurrences in the state with colon cancer and endometrial cancer close behind, he says.
One of the more widely seen malignancies, lung cancer has seen some declines, but it still takes the lead in mortality rate and long-term damage, he says. Lifestyle choices can have a substantial role in the prevalence of this cancer. “It is a bothersome issue that people are starting to do vaping, thinking vaping is okay and will not cause anything,” Desai says. He cites the nicotine in the liquid used for vaping as a concern for long-term healthcare. “We don’t know at this point in time what vaping might do, but it will cause some trouble down the road,” he says.
Taking proactive steps can have significant part in reducing the chances of developing a malignancy in the future. “Prevention is the most important for all of these things,” Desai says. “If you don’t smoke, lead a healthy lifestyle, and get preventive tests done, it’s less likely that one might have cancer.”
There are some factors in cancer prevalence that can relate to genetics and Desai says gene-based testing can help improve targeting if and when patients should be tested. It can also help better target treatments. “There is no question in my mind in terms of therapy for cancer. It is only going to get more complex,” he says. “What I’d like to see down the road are molecular tests that tell whose cancer is more serious and whose cancer is more slow-growing.”
Ephraim Casper, chief medical officer with Valley-Mount Sinai Comprehensive Cancer Care, says the cancers he and his team see are reflective of the types of cancer found in the community. In order to better address the care needs, he says Valley-Mount Sinai’s personnel is organized around disease types. The teams might collaborate bringing together medical, surgical, and radiation oncology disciplines with diagnostic specialists. “These programs are integrated and bring the latest technology to the patients,” Casper says. This specialized, collaborative approach is done through disease-specific tumor boards that discuss cases in a multidisciplinary way. That way patients may have more therapy options, he says.
Casper also comments that breast cancer is one of the most prevalent forms of cancer found in New Jersey, and his team has a number of ways to approach its treatment. Early diagnosis is naturally an essential part of care, and he says Valley-Mount Sinai offers robust diagnostic services such screening mammography, which is a low-dose x-ray for signs of cancer; diagnostic mammography; and mammographic biopsy. Treatment of breast cancer goes beyond addressing the illness. Casper says additional support services are made available, such as plastic surgeons who offer cosmetic resources after surgeries.
Other forms of cancer also have screening processes to detect potential malignancies and possibly improve outcomes. Casper says this includes low-dose CT screening for lung cancer, another illness with a high occurrence rate in New Jersey. There are times when doctors want to biopsy hard-to-reach spots on a patient. The rising use of technology that allows for precise procedures has further refined how cancer care is delivered. For example, the use of what is called a navigational biopsy system opens up access to some of those challenging places, Casper says. The goal is to offer accurate care with minimal intrusion on the patient. “We treat many patients with small incisions with the latest techniques,” he says.
Looking out for patients’ comfort is a continuing theme with other types of cancer care, including prostate cancer. Casper’s staff might use a protective hydrogel called SpaceOAR that is injected between the prostate and rectum so that when radiation is given, the prostate is spared from some of the side effects.
Getting ahead of cancer can be helpful in a treatment regimen, and understanding a patient’s genetics and family history play roles in the emergence of cases, Casper says. “We are increasingly appreciating the importance of genetics in cancer risk,” he says. There are a number of genes that increase risk, with BRCA genes most widely known for occurrences of breast and ovarian cancers. There is also a series of genes involved in Lynch syndrome (hereditary non-polyposis colorectal cancer) and endometrial cancer, he says, but even genetics can throw some curveballs. “We thought those were well understood, disease-specific cancer risk factors,” Casper says. BRCA genes have also been seen in pancreatic cancer and other gastrointestinal cancers. There is more work that needs to be done untangling the role genetics have in the development of specific types of cancer, but Casper sees such services as genetic counseling for patients as a way to start to better understanding risk. “Having a knowledge of genetic background helps identify those patients who need more intense screening,” he says.
Efforts are being made on the radiation oncology side to further fine tune care. For example, a traditional radiation treatment course might run for five to seven weeks, five days per week, says radiation oncologist David Wilson at the Virtua Samson Cancer Center in Moorestown. “The newer trend is to give a shorter number of treatments,” he says. “There’s some evidence that it can be more effective because the technology allows us to be more precise in controlling the cancer and more convenient for patients.” Using such an approach, skin cancers might be treated with a superficial radiation therapy that only requires 6 to 12 radiation treatments, when historically it could take up to 30 treatments, he says.
Wilson says his center treats breast, lung, rectal and metastatic cancers, as well as prostrate and other rare disease types. The use of newer equipment and procedures such as radiosurgery allows for focused radiation treatment on the brain, he says. Infrared technology is also used in what is called surface guided radiation therapy for some cancers, offering shorter treatment periods.
Meanwhile, Trinitas Comprehensive Cancer Center is the first and only cancer treatment facility in the state of New Jersey to offer its breast cancer patients Accuboost radiotherapy technology, an image-guided, non-invasive form of treatment. The accuracy and non-invasiveness of AccuBoost allows early stage breast cancer patients who have undergone a lumpectomy to retain more undamaged breast tissue, thus making a significant difference in patient outcomes. Accuboost is also up to 50% more accurate than standard breast radiotherapy.
“AccuBoost uses real-time mammography to localize the treatment,” says Clarissa Henson, MD, chair of radiation oncology at Trinitas. “With AccuBoost and image-guidance, targeting is improved and a more effective dose of radiation is delivered to the tumor site.”
AccuBoost is a novel, non-invasive image-guided breast radiation brachytherapy. By allowing doctors to see the site where cancer was removed and to treat the surrounding breast tissue area more effectively, Accuboost targets the extent of the disease and specifically treats the infected tissues. In this way, it identifies areas where cancer might likely reoccur if left untreated.
The image-guided feature of AccuBoost allows for the visualization of the tumor bed directly as the breast is immobilized and compressed through mammography. Imaging of the lumpectomy cavity is the first step in the accurate delivery of therapeutic radiation. The second and third steps involve delivery of radiation vertically and horizontally.
As the population improves other aspects of their lives, allowing them to live longer, the risks for cancer can increase in turn, according to Matthew Matasar, chief of the medical oncology service at Memorial Sloan Kettering Bergen. Many types of Non-Hodgkin’s lymphoma are more common with age, as are breast cancer and colon cancer, he says. “We’re living longer and with other advances in healthcare, there are more cancers that are likely to surface as we age,” Matasar says.
It is fortunate that some progress is being made in new approaches to fighting a variety of cancers. Matasar says there is a move away from more toxic treatments such as traditional chemotherapy and radiation therapy to using more sophisticated treatments that target specific enzymes or pathways within cancer cells. There are also efforts to use more immunotherapy to enhance the patient’s immune system to fight off cancer themselves.
He says there are four platforms where progress is being made in immunotherapy. The first is in developing a family of medicines called checkpoint inhibitors that, in a manner of speaking, cut the brakes on the parts of the immune system that cancers try to rely upon to hide. Cancer cells might find ways to mask their presence, but such medicines can restore the immune system’s ability to see and attack cancer cells.
Another approach Matasar cited is CAR-T cell therapy, which is based on chimeric antigen receptor modified T cells. In this therapy, healthy T cells are extracted, bioengineered, and then taught genetically how to attack cancer cells, he says. The cells are then grown and restored to the patient through a mini-transfusion.
The third platform uses what are called antibody-drug conjugates. “Normally, when you use antibodies to attack cancer, it is just a simple protein that attaches to the surface of the cancer cell made to kill the cell,” Matasar say. Antibody-drug conjugates work differently. These antibodies bind to and are absorbed by the cell – while hiding a secret. Attached to the antibody is a very powerful toxin that is snuck inside the cell like a Trojan horse. It is then released to kill the cancer cell. “It can be a very effective way to deliver a very powerful toxin that would be too toxic to give as an intravenous medicine,” Matasar says.
A fourth treatment with bond-specific antibodies is still in early development, he says, but it has potential. In such a treatment, an antibody attaches to a cancer cell, but it also bonds to a healthy immune cell such as the T cell. That forces the T cell to confront and kill the cancer cell. “These are easy treatments to administer and show tremendous promise in clinical trials,” he says.
There is a need, Matasar says, for greater participation in and understanding of clinical trials to support such efforts to better combat cancer now and in the future. His facility began operations 15 months ago and opened more 100 clinical trials across a range of cancer diagnoses, he says, with ambitions to perform even more. “We’re hoping to double that number in the next year,” Matasar says. “That includes developing a Phase 1 clinical trial program for the earliest medicines. Sometimes when there are no available treatments remaining, treatment with a Phase 1 experimental therapy can offer hope where there otherwise may have been none.”
Hackensack Meridian Health has teamed up with Memorial Sloan Kettering in a 10-year strategic partnership that will give patients more access to hundreds of clinical trials, including Phase I trials. The institutions are developing joint standards of care to be delivered across their existing sites, including Sloan Kettering’s facilities in Middletown, Basking Ridge and Montvale, and HMH’s John Theurer Cancer Center at Hackensack University Medical Center.
Additionally, the Theurer Cancer Center received approval earlier this year from the National Cancer Institute to become a research member of the Georgetown Lombardi Comprehensive Cancer Center Consortium, becoming one of just 16 NCI-recognized cancer centers in the nation. This consortium plans to advance research and innovative treatment in four key areas: breast cancer; cancer prevention and control, experimental therapeutics; and molecular oncology.
According to Bob Garrett, HMH CEO, “Our recent NCI designation with Georgetown allows us to conduct cutting-edge research. We’ve been attracting scientists who are conducting research in many cancer areas, including immunotherapy.”
HMH is also making inroads in cancer research at its Institute for Cancer and Infectious Diseases within its Center for Discovery & Innovation (CDI) located at the Interprofessional Health Sciences Campus in Nutley and Clifton.
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