2. www.providence.org/oregon FOR PHYSICIAN REFERRALS, SEE PAGE 7. Providence inScope | 32 | Providence inScope
B
efore Emily McKenna was diagnosed with cancer, the 39-year-old
physical therapist and mother of three was healthy. But in July of 2014,
she developed chest pressure, shortness of breath and dry cough. After
two weeks of these symptoms, Emily went to her primary care provider, who
performed an X-ray, revealing a large mass in the middle of her chest.
Her CT scan showed a mass in the left upper lobe. After a CT-guided
biopsy failed to diagnose her cancer, Emily was told she had metastatic lung
cancer. She knew the prognosis was unlikely to be good.
Emily then underwent a left thoracoscopy mass biopsy, and pathology
revealed she had diffuse large B cell non-Hodgkin lymphoma (DLBCL), the
most common type of non-Hodgkin lymphoma. However, studies of her
tumor revealed that she had a unique subtype, which is termed primary
mediastinal B cell lymphoma (PMBCL).
PMBCL, Emily’s type of non-Hodgkin lymphoma, typically affects young
women and requires specific treatment. The surgeon who took her biopsy
referred her to John Godwin, M.D., an oncologist specializing in blood cancers.
Dr. Godwin put a treatment plan together that included immuno-chemo-
therapy without radiation, based on observations from a 2013 study. Before
this study, Emily would have been treated with radiation, and her cancer
would have had a 20 percent chance of progressing.
For Emily, this new therapy has been successful. She does not require
radiation treatment and has avoided its long-term toxicities. Emily is looking
forward to her future. She plans to return to work and continue to watch her
three children grow up.
One patient’s experience with personalized
lymphoma treatment
ONE
TAILORED TREATMENT
FOR BETTER OUTCOMES
Tailoring treatment to the
biology of specific cancers
and individual patients is
changing the game in cancer
care. Here, oncologist Dr.
John Godwin and his patient
Emily McKenna illustrate how
understanding the biology of
a lymphoma and developing
individualized treatment can
make all the difference.
CANCER ATATIME
INSCOPE: What does Emily’s case teach us?
DR. GODWIN: Emily’s case illustrates the challenging
treatment decisions in non-Hodgkin lymphoma. DLBCL
should not be considered a single entity, and there is a
sizeable list of subtypes within the cancer.
As for Emily’s type of lymphoma, it is a highly aggressive
non-Hodgkin lymphoma, recognized as a separate entity
in the 2008 World Health Organization’s classification of
lymphomas. Genes expressed in PMBLC are more closely
related to classical Hodgkin lymphoma. Its clinical features
include a tendency to occur in young women and to grow
as a localized bulky mass in the chest.
INSCOPE: How does insight into these subgroups
and their biology influence treatment?
DR. GODWIN: Treatment standards for PMBCL have not
been established, since few prospective studies have been
conducted. However, some important observations have been
made. CHOP, a chemotherapy regimen used in the treatment
of non-Hodgkin lymphoma, is insufficient in PMBCL.
In PMBCL, addition of rituximab to CHOP, termed
immunochemotherapy or RCHOP, is more effective than
CHOP alone. Immunochemotherapy is the combination of
immunotherapy, the use of a patient’s own immune system
to fight the disease, with chemotherapy. However, most
patients have residual masses and still require radiation after
undergoing RCHOP. About 20 percent of patients treated with
both radiation and RCHOP will still progress, indicating the
inadequacy of this therapy.
Fortunately for Emily, a recent study published in 2013 used a
new approach to immunochemotherapy called DA-EPOCH-R
that showed a 97 percent survival at a median of five years;
only 4 percent of these patients needed mediastinal radiation.
This new treatment incorporates an individualized
chemotherapy dose based on a patient’s blood cell tolerance
and extended drug exposure. In other words, Emily’s
treatment was tailored to both the biology of her cancer and
her biological response to treatment.
INSCOPE: So, when it comes to lymphomas, one
size does not fit all?
DR. GODWIN: That’s correct. Understanding these subgroups
has led to the development of targeted treatments to
improve patient outcomes. Future treatments will evolve
based on improved understanding of the underlying disease
mechanisms. With lymphomas, careful disease classification
and tailored treatment are important. n
INSCOPE: What is special about the classification
of lymphomas?
DR. GODWIN: The classification of lymphomas has gone from
a simplistic grouping of cancers that all look the same under a
microscope, and are believed to have similar clinical behavior,
to a complex molecular classification of individual lymphomas.
Because of the rapidly changing treatment paradigms for
lymphoma, enlisting the expertise of physicians specializing in
lymphoma can help assure the best treatment plan.
INSCOPE: How was Emily’s treatment challenging?
DR. GODWIN: Understanding the natural history of
the lymphoma subgroups, and recent insights into their
biology, can change the diagnosis and treatment of specific
lymphomas. Although Emily’s cancer was rare, it’s important to
diagnose all lymphoma cancer subgroups accurately, and treat
them according to the most recent observations.
John Godwin, M.D., medical oncologist
Providence Cancer Center Oncology and
Hematology Care Clinic Eastside
Providence Portland Medical Center
4805 NE Glisan Street, Suite 6N40
Portland, Oregon 97213 • 503-215-5696
Deeper understanding
of lymphomas leads
to better treatment
AN INTERVIEW WITH DR. JOHN GODWIN,
EMILY’S ONCOLOGIST
Emily McKenna (above right)
was diagnosed with a rare
subtype of lymphoma.
Thanks to recent insights into
the biology of this cancer and
the targeted treatment, Emily
is now cancer free.
3. www.providence.org/oregon4 | Providence inScope FOR PHYSICIAN REFERRALS, SEE PAGE 7. Providence inScope | 5
Consultation and screening of high-risk
breast patients
F
or women, breast cancer is the
most common cancer in the
United States and across the
globe. And for patients facing breast
cancer, the path to treatment is often
clear. But to the sisters, daughters
and other relatives of a breast cancer
patient, the future can be uncertain
and full of anxiety.
Reducing anxiety in cancer
patients and their loved ones
As a medical oncologist, I have
treated many women for breast
cancer and have screened their
daughters for the same disease. The
worry for sisters and daughters is
often evident in the faces of women
being treated. They wonder if they’re
passing on the disease to someone
they love.
I often tell the relatives of these
patients to seek a high risk program
that can help assess their personal-
ized risks for breast cancer, in
addition to tracking family history.
While mammography is a well-
validated way to screen for breast
cancer in its earliest stages, we feel
that preventing breast cancer in high
risk women is an even better goal.
One-year-old clinic offers
consultations to high-risk
patients
Consultation services like this are
available to those who are at highest
risk for a potential future breast
cancer diagnosis at Providence’s
High-risk Breast Care Clinic, which
is part of Providence Cancer Center.
The clinic is open for both men and
women, and has locations on the
east and west side of Portland, both
of which opened within the last
year. In 2014, both clinics served
234 patients for breast cancer risk
factors, coordinated with primary
care providers and offered patients
useful advice for prevention.
Developing personalized
plans for breast cancer
prevention
When a patient comes to an
appointment at the clinic, he or she
answers questions about family
history, receives a clinical exam and
is given a personalized plan to
minimize risk of developing breast
cancer or to treat the cancer. We
assess patients who are seen at the
clinic using several risk models. We
communicate directly with the
patient’s primary care provider and
schedule exams and follow-up
appointments as needed.
Identifying those who are at
an elevated risk
All women are at risk for breast
cancer, but the clinic works to
identify the populations of women
who are at an elevated risk. Patients
Alison Conlin, M.D.
Medical oncologist; medical director
Providence Breast Care Clinic East
Providence Portland Medical Center
4805 NE Glisan Street
Portland, Oregon 97213 • 503-215-7920
at the highest risk for future breast
cancer include women with a family
history of breast or ovarian cancers;
or those who have had a prior breast
biopsy showing atypical ductal
hyperplasia, atypical lobular
hyperplasia or lobular carcinoma in
situ; or have a proven gene mutation
in BRCA1 or BRCA2; or have had
radiation treatment on the chest
between the ages of 10 and 30.
Counseling patients with
dense breasts
A recently passed Oregon law also
mandates that heath care facilities
with mammography services advise
patients with dense breast tissue that
having dense breasts may be
associated with an increased risk of
breast cancer. Women who receive
this notice or have heterogeneously or
extremely dense breasts can also be
seen and counseled about their
individual risks at a high-risk breast
care clinic.
Helping determine when
medication is indicated
Another treatment option for
prevention in women at a higher risk
for breast cancer is in the form of
medication. Several clinical trials
have shown that breast cancer risk is
reduced by 50 to 60 percent with the
use of tamoxifen or the aromatase
inhibitors. For primary care providers
unsure about prescribing these
medications, a high risk breast care
provider is able to assess whether this
a measure that may be best for the
individual patient.
High-risk breast center and
primary care providers work
together for best preventive
treatments
Providing individualized risk
assessments for breast cancer and
other hereditary types of cancer can
give peace of mind and empower-
ment to people who know their
family history includes the disease.
It can also support primary care
providers in navigating breast cancer
risks in their patients and determin-
ing the best preventive care for each
patient. By working together, we have
the opportunity to prevent some
cancers, and identify others early. n
Navigating Oregon’s new
breast density law
In January 2014, Oregon became the eleventh state to pass a law directing
health care facilities that provide mammography services to advise patients
with dense breast tissue that having dense breasts may be associated with
an increased risk of breast cancer.
Required notifications can worry patients
These facilities are required to send patients who have heterogeneously
and extremely dense breasts notices that encourage them to talk to a
health care provider about the risk of breast cancer associated with having
dense breast tissue.
While a notice like this may alarm patients, it is important to note that
nearly 50 percent of women have heterogeneously or extremely dense
breasts. It is not a rare condition, and represents a description of the fatty
and glandular tissue
distribution in the breast.
Dense breast tissue may
sometimes make it more
difficult to spot cancer
on mammograms.
Notification should, in
some cases, change
screening methods
For some patients,
supplemental screening
like an ultrasound or magnetic resonance imaging (MRI) test may be
helpful in screening. High breast density alone is not considered a
significant risk factor for developing breast cancer, but women should be
queried for other risks, as well, to get a more accurate picture of overall risk.
Breast density generally declines as women age, so a patient with dense
breasts to begin with may not necessarily have dense breasts for her
lifetime. A study conducted at New York University Lagone Medical Center
showed that of more than 7,000 women, nearly three-quarters of those in
their 40s had dense breasts, compared to 57 percent in their 50s, 44
percent in their 60s and 36 percent in their 70s.
High-Risk Breast Care Clinic can provide evaluations
In addition to other services, Providence’s High Risk Breast Care Clinic also
provides evaluation for patients who have been notified of high breast
density. Patients who come to the clinic because of dense breast tissue are
also assessed for risk from family history, prior conditions, lifestyle and
other factors. If enough risk is present, the patient may be encouraged to
undergo additional screening.
If a patient is worried about breast cancer risk, this clinic can serve to
provide reassurance by education on protective measures like avoiding
hormone replacement after menopause, limiting alcohol intake, eating
more fruits and vegetables, increasing exercise and losing weight,
if necessary.
3OF 100
women who develop
breast cancer have a
BRCA1 or BRCA2 mutation.
10 EVERY100
women who develop
ovarian cancer have a BRCA1
or BRCA2 mutation.
OF
ACCORDING TO THE CDC,
GENETIC TESTING
MAY BE USEFUL FOR AN
INDIVIDUAL WHO HAS HAD:
One (or more) first- or second-
degree relative(s) with:
Primary cancer of both breasts
•••
Both breast and ovarian cancer
in the same relative
•••
Male breast cancer
OR
Two or more first- or second-
degree relatives with:
Breast cancer, if at least one
breast cancer was diagnosed
before age 50.
•••
Breast and ovarian cancer
in different relatives.
•••
Ovarian cancer, diagnosed
at any age.
OR
Three or more first- or second-
degree relatives with breast
cancer at any age.
4. 6 | Providence inScope Providence inScope | 7www.providence.org/oregon
inPractice
Referral
RESOURCES
SUBSCRIBE TO OUR CLINICAL NEWSLETTERS
www.providenceoregon.org/clinicalnews
PROVIDENCE EXECUTIVE ADVISORY BOARD
Doug Koekkoek, M.D., chief executive
Providence Clinical Services, Providence
Medical Group
Tom Lorish, M.D., chief executive
Providence Outreach
Doug Walta, M.D., chief executive
Providence Clinical Programs
CONTACT PROVIDENCE INSCOPE
James Watson, editorial director, 503-893-7259
facebook.com/providence @provhealth
noteWorthy
When your patients need
advanced care, our specialists
are right at your fingertips.
Call toll-free 844-ASK-PROV
(844-275-7768) for:
n Urgent consults and transfers,
day or night
n Non-urgent consults and referrals,
9 a.m. to 5 p.m., Monday-Friday
More resources
General information line
503-574-6595
Integrative medicine
East metro: 503-215-3219
West metro: 503-216-0246
Home services
503-215-4321
Regional lab services
503-215-6660
Rehabilitation services
503-574-6595
www.ProvidenceOregon.org
Kate Newgard, RN, BSN, OCN
Oncology nurse navigator, Providence
Cancer Center at Providence Medford
Medical Center
Distinctions
Founded programs at Providence
Medford Medical Center, including
one started in Jan. 2013 that screens
patients for hereditary cancers,
including breast cancer, and
provides patient support,
information, screening and testing.
Past lives
RN, BSN, OCN degrees, Southern
Oregon University; oncology
certified nurse since 1996; breast
health care nurse certificate
How does oncology
navigation help patients?
Navigation has shown to help
patients in many ways. It improves
patient outcomes, assists with
interpretation of medical informa-
tion and provides support for
patients without family, among
others.
Why did you start the
hereditary cancer screening
program?
As the breast cancer navigation role
evolved, it became clear that we
needed to address cancer risk for
women who have not been
diagnosed with breast cancer but
have a family history of breast
cancer. That led to the evolution
of our risk-assessment program.
The program offers complete
screening and assessment for
hereditary cancers and provides
women with the medical
information they need in an
emotionally supportive
environment. If an individual
decides to undergo genetic testing,
Dr. Nancy Hagloch, a gynecologist
and surgeon at Providence Medford,
works with the patient to help
provide any necessary follow-up
testing and care.
What kinds of cancers are
connected to genetics?
Breast, ovarian, colon, uterine,
pancreatic, prostate, melanoma and
gastric cancers can be heredity,
among others.
What happens at a screening
appointment?
I allow 90 minutes per appointment,
and provide a family assessment, as
well as written, verbal and video-
delivered information for individuals
regarding the testing. I also include
breast cancer risk modeling when
appropriate and information about
breast density.
What keeps you coming to
work every day?
The education we provide helps
diminish fear and anxiety for
people. Only about five to 10
percent of most cancers are related
to an inherited gene. We also help
patients identify factors they can
control to reduce their cancer risk,
such as diet, weight and exercise. I
hope that patients gain a better
understanding of this complex
topic and that the information we
provide helps to diminish their fear
as well as prevent some cancers. n
New website provides searchable cancer
trial database
Providence’s new clinical trials website allows providers
to search by keyword or filter by cancer type to learn
about trials and studies underway at Providence
Cancer Center. Patients may take part in studies
initiated by the Robert W. Franz Cancer Research
Center in the Earle A. Chiles Research Institute, in
addition to studies sponsored by the National Cancer
Institute or pharmaceutical and biotechnology
companies. Our clinical trials team works with
physicians to identify trials appropriate for each
patient. For more information, call 503-215-6014.
Providence Medical Group names director of access strategies
Providence Medical Group-Oregon has named a new director of access
strategies. Wendy Carlton took over the position in late January. For the
last three years, she was the chief operating officer for Providence Medical
Group in Southeast Washington – Walla Walla. As the director, Carlton
will develop operational plans and access strategies for all Providence
Medical Group patients including a continuum of clinical access – from
retail clinics to immediate and primary care.
Providence hospital earns recognition for diagnostic imaging
Providence Portland Medical Center was designated a Diagnostic Imaging
Center of Excellence by the American College of Radiology (ACR) in late
2014. Providence Portland’s diagnostic imaging team performs 180,000
exams a year, including radiology, mammography, CT scans, MRIs,
ultrasounds, bone density tests, nuclear medicine procedures and PET
scans. The three-year designation calls out excellence in superior patient
care, professionalism and quality technology, among others.
Providence Medical Group names three medical directors
Deborah Satterfield, M.D., has been named Providence Medical
Group-East area medical director. Dr. Satterfield was named one of
Portland’s Top Doctors in 2012 and 2013, and was named OHSU Family
Medicine Teacher of the Year in 2001. Linda Cruz, M.D., has been
named Providence Medical Group-West area medical director. Dr. Cruz has
successfully led work in the areas of persistent pain, chemical dependency
referral and integration of psychiatry in the clinic. Karen Kronman, M.D.,
a practicing OB-GYN with PMG-South since 2004, has been named
PMG-South area medical director.
Find your
perfect practice
Providence Health & Services offers
several practice opportunities in
Oregon. Here you’ll enjoy:
n A strong team culture
n Competitive compensation
n Work/life balance
n Employed and private-
practice options
n Flexible work models
n Beautiful, family-friendly
communities
Please call Providence Physician
Services and Development at
1-866-504-8178.
www.providence.org/physicianopportunities
5. Topics include:
Checkpoint inhibitors (PD-1, CTLA-4) • Co-stimulatory agonists (OX40,
41-BB, LAG-3) • Cytokines • Vaccines • Immunoscore • Radiation
and immunotherapy • Emerging clinical trials • Future directions
Keynote speakers
• Robert Ferris, M.D., Ph.D., University of Pittsburgh
• Tom Gajewski, M.D., Ph.D., University of Chicago
• Dario Vignali, Ph.D., University of Pittsburgh
• James Yang, M.D., Ph.D., National Institutes of Health
Invited speakers
• Lisa Coussens, Ph.D., Oregon Health and Science University
• Young Kim, M.D., Ph.D., Johns Hopkins University
• Holbrook Kohrt, M.D., Ph.D., Stanford University
• John Lee, M.D., Ph.D., Sanford Health
• Sara Pai, M.D., Ph.D., Harvard University
• Andrew Sikora, M.D., Ph.D., Baylor University
• Scott Strome, M.D., Ph.D., University of Maryland
• John B. Sunwoo, M.D., Ph.D., Stanford University
• Gregory Wolf, M.D., Ph.D., University of Michigan
Course directors
• R. Bryan Bell, M.D., DDS, FACS
• Marka Crittenden, M.D., Ph.D.
• Bernard Fox, Ph.D.
• Rom Leidner, M.D.
• Walter Urba, M.D., Ph.D.
• Andrew Weinberg, Ph.D.
Accommodations
The Allison Inn & Spa, Newberg, Oregon
503-554-2525 or 877-294-2525
www.theallison.com
Registration
• Registration is $400, with $75 for a spouse or other guest. Course fee
includes continental breakfast, lunch, refreshment breaks, reception,
dinner and syllabus. Payment is due upon registration.
• To register online, visit www.pfiedlerenterprises.com/courses.htm.
For fax or mail registration, download and complete the registration
form. Then send it by fax to 720‑748‑6196 or by mail to:
Pfiedler Enterprises
2101 S Blackhawk Street, Suite 220
Aurora, CO 80014
Learn more
For more information about the conference or for help with registration,
contact Pfiedler Enterprises at 720-748-6144.
The Earle A. Chiles
Research Institute
at Providence Cancer Center
invites you to
New Horizons in
Immunotherapy
for Head and
Neck Cancer
Aug. 14-16, 2015
The Allison Inn & Spa
Newberg, Oregon
This continuing medical education event
is approved for MA PRA Category 1
Credit, and is sponsored
by Pfiedler Enterprises.
