Under the guidance of noted urologist Mitchell C. Benson, MD, urologic oncology care at NewYork-Presbyterian/Lawrence Hospital has evolved into a comprehensive program that utilizes personalized medicine, precision management and advanced surgical techniques to improve outcomes for patients in the local community.
Recent events in the field of urology — such as the advent of molecular profiling of prostate cancer and the need for smarter standards of treatment in the wake of U.S. Preventive Services Task Force recommendations against prostate-specific antigen (PSA) testing — highlight the need for leading-edge, customizable services in this specialty.
In that environment, the guidance of a urology veteran and progressive leader such as Dr. Benson becomes invaluable to the health of area patients.
“At NewYork-Presbyterian/Lawrence, we consider the treatment of urologic cancers one of our disease-focused priorities,” says Maureen Killackey, MD, FACS, FACOG, Clinical Director of Cancer Services at NewYork-Presbyterian/Lawrence. “Prostate cancer, bladder cancer and other urologic concerns are all too common in the communities we serve. To combat that, we have invested in expanding on the strong bones of our urologic team, creating the infrastructure and cultivating the talent necessary to treat these diseases holistically and comprehensively. The addition of Dr. Benson is an essential element of that program’s success.”
Mitchell C. Benson, MD, urologist, urologic oncology care at NewYork-Presbyterian/Lawrence Hospital, and Henry J. Lee, MD, PhD, Director and Chair of the Department of Radiation Oncology and Assistant Professor of Radiation Oncology with NewYork-Presbyterian/Columbia University Medical Center, work together to treat cancer patients at NewYork-Presbyterian/Lawrence Hospital in Bronxville.
Focus on Prostate Cancer
Dr. Benson’s program individualizes prostate cancer management to the molecular level when appropriate, starting with the screening process.
Dr. Benson meets with a patient at his NewYork-Presbyterian Medical Group/Westchester office in Scarsdale.
“I consider the U.S. Preventive Services Task Force recommendation against PSA screening a very dangerous one,” he says. “If we stop PSA screening, there is nothing to stop history from repeating itself. Men are going to present with metastatic disease and die. However, we also have to recognize that the PSA test does have limitations. To effectively use the tool of PSA screening and guide care appropriately, we have to understand that prostate cancer is a spectrum of disease.”
Dr. Benson describes two hypothetical men. One is 88, lives in a nursing home and dies after complications from a fall. An autopsy discovers microscopic levels of cancer in his prostate. He had the disease, but it was not clinically significant and in all likelihood, never would have been.
Chief Radiation Therapist Jill Giorgi, RTT, stands at the linear accelerator’s (LINAC’s) control console with Dr. Lee.
The second scenario highlights the opposite end of the disease spectrum. A 45-year-old man develops an aggressive form of prostate cancer. If it isn’t discovered, treated and cured in a timely manner, the likelihood of the disease metastasizing elsewhere in the body and threatening his life is extremely high. In this scenario, a PSA test leading to biopsy, analysis, diagnosis and targeted therapy would likely be the most effective path to saving his life. So what is the difference? Both men had the same disease, but their clinical needs and the appropriate medical responses to the disease itself are vastly different. Even if the first man’s cancer had been identified during his lifetime, invasive care would have been inappropriate.
The program at NYP/Lawrence is designed to meet the needs of patients whose cases fall at either end of this spectrum or anywhere in between, using risk-factor analysis and an understanding of the mechanisms behind tumor growth to guide care.
“There is no such thing as over-diagnosis, only over-treatment,” Dr. Benson says. “The fact remains that today, in 2016, a large percentage of men diagnosed with prostate cancer can be safely managed with no initial treatment.”
Dr. Benson and his colleagues use this approach, called active surveillance — active monitoring of the cancer — to prevent unnecessary procedures, guide schedules of follow-up biopsies and initiate care when waiting is no longer in the best interest of the patient.
The use of molecular profiling that searches blood for a combination of biomarkers for prostate cancer is a key tool that helps Dr. Benson decide when waiting is appropriate and when it is time for action. The test can identify hallmarks of aggressive cancers, assisting clinicians in decision making, whether it’s increasing the frequency of biopsies or moving patients on to the next step — treatment.
NYP/Lawrence was the first hospital in Westchester County to bring on board the most recent iteration of a popular, state-of-the-art robotic surgery system — a machine Dr. Benson uses to assist in the treatment of urologic cancers such as those of the bladder, kidneys and prostate.
“Initially, robot-assisted systems allowed us to perform urologic surgery more precisely but at the cost of efficiency,” he says. “As the platform improves, so does the ease and speed with which we can perform these procedures. Now, the system allows us to adjust camera angles without changing the lens, saving precious minutes during surgery. Less time on the operating table means better patient outcomes, but even before this improvement, I have never had to perform a blood transfusion on a patient undergoing robotic urologic surgery.”
To prepare for the surgical resection of prostate tumors or the prostate itself, Dr. Benson utilizes high-powered MRI to collect data about the gland. Knowing the precise location of the tumor, as well as whether the prostate capsule of connective tissue is intact, and whether the cancer has spread to the surrounding lymph nodes, allows him to plan effective procedures and minimize side effects such as decreased sexual function.
“Over the past five years, the magnets used in an MRI have become more powerful, and the computer that analyzes the tremendous wealth of data those magnets collect has as well,” Dr. Benson says. “Tailoring operations to patients’ specific anatomy minimizes the effect we have on the nerves and blood vessels that run along the surface of the prostate. We know precisely how much tissue to remove for the best possible outcomes that eliminate cancer cells effectively without removing too much.”
Organ Preservation and a Wider Scope
The robotic surgical system also plays a star role in the removal of kidney cancers at NYP/Lawrence. The goal in these procedures is to remove malignancies and resolve disease while preserving as much of the organ as possible.
“We have known for years that a person who donates a kidney for a transplant is at a higher risk of developing kidney failure in the future,” Dr. Benson says. “Now, we are finding that the best practice is to apply that information to patients with kidney malignancies as well. Unless the nature of the disease is such that it makes this option impossible, patients should be able to retain the kidney after surgical resection of localized tumors. We can also provide patients information about organ salvaging.”
Maureen Killackey, MD, FACS, FACOG, is the Clinical Director of Cancer Services at NewYork-Presbyterian/Lawrence Hospital in Bronxville.
Innovative intravesical immunotherapy for bladder cancer has a similar goal of organ preservation. Dr. Benson routinely prescribes Bacillus Calmette-Guerin (BCG) therapy for non-invasive, early-stage bladder cancer. BCG is delivered directly to the bladder via catheter. This therapy attracts the attention of the body’s immune system to the bladder, where the cancer is attacked and, ideally, neutralized by the body’s own defense mechanism, eliminating the need for more invasive therapy.
“If bladder cancer is more advanced and BCG is not an option, the goal is still to preserve the organ if at all possible,” Dr. Benson says. “There has been a lot of research and experimentation to discover new treatments in this area, and we offer the latest advances.”
Treatment modalities include the use of medications such as docetaxel and customized cocktails of chemotherapy medications pumped directly into the bladder, which often prove effective in halting disease progression. If bladder removal surgery becomes necessary, Dr. Benson uses minimally invasive, robot-assisted techniques to deal with these cancers in a similar way to his approach to prostatectomy. Interdisciplinary clinical follow-up assists these patients as they transition back to their normal routines.
A New Addition — Radiation Oncology
Dr. Benson installs a port on a patient undergoing a robotic prostate surgical procedure.
Another essential element of the well-rounded urologic oncology program at NewYork-Presbyterian/Lawrence is the addition of a radiation oncology program. Continuing the theme of recruiting high-quality providers, the enterprise brought on Henry J. Lee, MD, PhD, to serve as Director and Chair of the hospital’s newly established Department of Radiation Oncology. Dr. Lee is also an Assistant Professor of Radiation Oncology with NewYork-Presbyterian/Columbia University Medical Center.
“I function as one of the three cornerstones of the disease management team for urologic oncology patients, working closely with my urologic surgical and urologic medical oncology colleagues,” Dr. Lee says. “Our multidisciplinary oncology care program is linked to the existing program at NewYork-Presbyterian/Columbia University Medical Center. We follow an academic model that only serves to further enhance the quality of urologic cancer care available at NewYork-Presbyterian/Lawrence.”
Together with Dr. Benson and medical oncologist Michelle Boyar, MD, Dr. Lee and other members of the Cancer Care Team participate in Case Conferences to discuss the care of patients with urologic cancers. For those with prostate or other cancers that have advanced beyond the realm of active surveillance or other conservative methods of care, Dr. Lee will recommend a variety of treatment options, including intensity-modulated radiation therapy, image-guided radiation therapy, stereotactic radiosurgery and other forms of radiation therapy modalities using the linear accelerator (LINAC).
Dr. Lee stands in front of the hospital’s state-of-the-art linear accelerator (LINAC). The new radiation therapy system treats cancer with photon beams instead of radioactivity.
“We embody this concept of true multidisciplinary urologic oncology care from a disease management team and have introduced that academic model to the Westchester community.”
— Henry J. Lee, MD, PhD, Director and Chair, Department of Radiation Oncology, NewYork-Presbyterian/Lawrence Hospital
“When our Cancer Center opens, this machine will allow us to use image-guided radiation therapy that accounts for movement and location like never before,” Dr. Lee says. “It is the latest iteration of radiation technology and the first time that technology has been developed from the ground up to enable us to deliver better treatment with pinpoint accuracy and ease.”
Anna Gavazzi, RN, a nurse in Dr. Benson’s office, discusses a case with medical assistant Teneisha Elliott.
Dr. Lee considers convenience one of the core elements of the anticipated radiation oncology program at NewYork-Presbyterian/Lawrence. The linear accelerator is capable of delivering radiation therapy that is administered to the patient over a period of weeks or days by breaking up doses into fewer but higher-intensity sessions. Hypofractionated radiation therapy takes less time and fewer sessions, allowing patients to maintain more normal schedules without sacrificing the quality of care necessary to effectively treat their cancers.
“Virtually all men with prostate cancer are excellent candidates for external beam radiation therapy,” Dr. Lee says. “Patients are typically able to work while they undergo treatment, as well as exercise, have regular diets and otherwise live normal lives. It’s a very positive experience thanks to the nature of the treatment and the environment in which it is completed.”
Though the program will be new to NYP/Lawrence, the radiation oncology team is highly trained and experienced in the field. The recruitment of each member was rigorous and focused on his or her expertise and compassionate care. Moreover, many are locals, increasing their investment in the well-being of the communities where they work and live.
Dr. Benson joined the staff of NewYork-Presbyterian Medical Group Westchester in December 2015. He’s also a member of ColumbiaDoctors and is a Herbert and Florence Irving Professor of Urology.
“With prostate cancer, you have to individualize care. It is one cancer for which one size certainly does not fit all.”
— Mitchell C. Benson, MD, Attending Physician, NewYork-Presbyterian/Lawrence Hospital, and Herbert and Florence Irving Professor of Urology, Columbia University
Radiation oncology will continue to advance at NewYork-Presbyterian/Lawrence. An upcoming expansion of the treatment roster — brachytherapy — introduces an additional element of prostate cancer treatment to the program.
“In brachytherapy, we implant dozens of radioactive seeds to the prostate,” Dr. Lee explains. “These seeds emit radiation therapy directly at the site of the cancer. It can be used as a stand-alone treatment option or combined with other treatment modalities.”
While brachytherapy is technically a surgical procedure, it is completed without an incision or stitches and is considered a bloodless process. The location of the prostate makes it ideal for easy brachytherapy seed implantation.
By bringing in the latest advances in urologic cancer treatment as well as leaders in the field such as Dr. Benson and Dr. Lee, NewYork-Presbyterian/Lawrence sends a clear message to the communities the hospital serves as well as the physicians who refer patients to the program — urologic cancer care here is adaptable, innovative and on point. The hospital has emerged as the leader in urologic cancer detection and treatment in Westchester.
“When patients enter the oncology program at NewYork-Presbyterian/Lawrence, we create a relationship that will last the rest of their lives,” Dr. Killackey says. “Our teams focus on survivorship and a return to wellness. We are always here for our patients. Community outreach, risk reduction, education and collaboration with the primary care providers whose patients we care for are as essential to our mission of holistic service as treatment.”
For information about urologic cancer care at NewYork-Presbyterian/Lawrence Hospital, visit www.nyplawrence.org.