The NewYork-Presbyterian Lawrence Hospital Cancer Center leverages the academic and clinical prowess of Columbia University Irving Medical Center specialists to provide patients in the Bronx and Westchester areas with accurate, comprehensive diagnoses and leading-edge therapies made possible by advances in precision medicine.
By incorporating the rapidly evolving benefits of precision medicine, NewYork-Presbyterian Lawrence builds on its longstanding commitment to delivering high-level care in the region.
Defining Precision Medicine
The Precision Medicine Initiative (PMI), launched in 2016, defines precision medicine as an approach to preventing and treating disease “that takes into account individual variability in genes, environment and lifestyle for each person.” This fosters greater accuracy in customizing prevention and treatment strategies that work best in particular patient groups, rather than focusing on the average patient with little regard to variation among individuals.
Some aspects of precision medicine, such as matching donor and recipient blood types for transfusions, were in practice long before the term came into widespread use, notes the National Institutes of Health, which is part of the PMI. However, clinical research has moved the field forward to an astonishing degree, notably in oncology.
NYP Lawrence and a dedicated team of Columbia University Medical Center (CUMC) specialists embrace the potential of precision medicine with an approach comprising everything from examining cancer patients’ family histories and analyzing patients’ hereditary predispositions toward cancer to determining and applying the most effective courses of treatment based on evaluations of tumor genetics.
Henry Lee, MD, PhD, is Director of Radiation Oncology at NewYork-Presbyterian Lawrence Hospital and an active member of Columbia University’s Herbert Irving Comprehensive Cancer Center. As a leader in the field, Dr. Lee utilizes the latest technologies to treat patients with precision medicine tools that zero in on tumors and spare healthy tissues.
“Every patient can benefit from precision medicine,” says Henry J. Lee, MD, PhD, Director of Radiation Oncology at NYP Lawrence and Assistant Professor of Radiation Oncology at CUMC.
Precision medicine permits personalized treatments for a range of cancer types — ovarian, skin, colorectal, lung and breast, to name just a few. In each case, the best management of each patient’s cancer is determined by that individual’s tumor characteristics.
In breast cancer cases, for example, clinicians first determine if tumors are hormone-receptor-positive (HR-positive). About 70 percent of breast cancers are HR-positive, according to the American Cancer Society. Tumors can be estrogen-receptor-positive (ER-positive), progesterone-receptor-positive (PR-positive) or both.
Recently released results from the multinational Trial Assigning Individualized Options for Treatment (Rx) (TAILORx) study illustrate how such personalized analysis can result in individualized modifications to treatment plans for people with certain types of cancer. As illustrated in TAILORx, oncologists now know that among women with HR-positive, human epidermal growth factor receptor 2-negative (HER2-negative) cancers, 70 percent of lymph node-negative patients do not require chemotherapy and instead respond equally well to hormonal therapy alone after surgery.
As Associate Director of the Breast Disease Management team, Carolyn Wasserheit, MD, works with many members of the Cancer Center team to coordinate care plans for patients before, during and after treatment.
“There are patients who come in with some knowledge about what treatments are available, perhaps wondering why they aren’t getting a therapy they read about on the internet or learned of from a family member or colleague,” says Carolyn Wasserheit, MD, medical oncologist, Director of Breast and Gynecologic Projects and Associate Director of the Breast Disease Management Team at NYP Lawrence, and Assistant Professor of Medicine at CUMC. Sharing the latest research with newly diagnosed, early-stage patients and informing them about the results of their individualized tumor characteristics, and, if applicable, available genetic profiling of their tumor are important parts of a consultation. A significant number of patients can be spared from receiving chemotherapy and still have confidence that less-taxing treatments have a similar likelihood of preventing recurrence, Dr. Wasserheit notes.
“I explain that not every breast cancer is the same,” she says. “If your friend is getting a specific therapy, it might be that their situation is different; you’re your own unique person.”
But even for early-stage cancers, specific approaches may be indicated, particularly when patients’ genetic backgrounds reveal a predisposition to cancer. According to the National Cancer Institute, inherited mutations are a factor in 5–10 percent of all cancers.
Dr. Wasserheit oversees the genetics program at NYP Lawrence, and three key factors spur a referral from her or other physicians for genetic counseling: patients whose cancer occurs before ages 45 to 50, patients who have a family history of the same type or related cancers, or patients with certain less-common illnesses, such as ovarian cancer. Multiple cancers in the same individual or triple-negative tumors — ER/PR/HER2-negative — also can trigger a referral.
“My recommendation for therapy is individualized. Treatment is based on the characteristics and stage of the tumor, as well as the underlying medical problems of the particular patient. Not every breast cancer is the same. Medical oncology is becoming vastly more personalized. Every patient is an individual.”
— Carolyn Wasserheit, MD, medical oncologist, Director of Breast and Gynecologic Projects and Associate Director of the Breast Disease Management Team at NYP Lawrence, and Assistant Professor of Medicine at Columbia University Medical Center
Dr. Lee and a radiation oncology therapist review treatment of a patient using the Hospital’s state-of-the-art linear accelerator located conveniently in the Cancer Center.
NYP Lawrence genetic counselor Leyla Tabanfar, MS, CGC, who also works at Columbia, guides patients in deciding which genetic tests would provide the most valuable information.
“We can test for panels of multiple genes. Two decades ago, cancer genetic testing was basically for BRCA1 and 2. Now there are close to 20 genes we can test for hereditary breast cancer, and we know of nearly 70 genes that predispose to different kinds of cancers,” Tabanfar says. “Some patients are predisposed to various kinds of colorectal cancers, for instance. Once we determine that, we can use regular colonoscopies to detect colorectal cancer early or remove early polyps.”
As with treatment, NYP Lawrence carefully tailors genetic testing to a patient’s individual needs and clinical and family histories, rather than automatically performing broad-spectrum testing on every patient, which can create anxiety without being informative.
Tabanfar consults with patients further if results are positive, and the medical recommendations can be much more aggressive. For breast cancer patients with a BRCA1 mutation, for example, the breast cancer disease management team might recommend risk-reduction surgery, such as double mastectomy or removal of the ovaries. Those are not easy decisions, but having access to reliable information about germline mutations — those that parents pass on to their offspring — empowers patients in charting an informed course of treatment, Tabanfar says.
Leyla Tabanfar, MS, CGC, is one of the Cancer Center’s newest team members. The genetic counselor advises patients on appropriate genetic testing options. She then prepares an action plan to guide the patient and specific family members with strategies to reduce their cancer risk factors.
Presently, while hereditary genetics testing plays an important role in management of some cancers, learning more about tumors can provide insight into virtually every type of cancer, according to Dr. Lee. NYP Lawrence’s pathologists use a range of tests to analyze tumors in collaboration with Columbia pathologists.
In addition to testing to determine a recurrence score for applicable early-stage breast cancer patients, other genomic and biomarker analyses are used in metastatic breast cancer tumors and non-small cell lung, colorectal and ovarian cancers, as well as melanomas.
“These and other tests identify a patient’s unique alterations in a tumor’s proteomics, genomics and epigenetics,” Dr. Lee says. Analyzing those molecular biomarkers helps physicians customize treatment.
“Precision medicine has the potential to improve the therapeutic index of radiation therapy in particular by allowing the radiation oncologist to individualize a patient’s treatments to a degree far greater than we’ve been able to do over the past 100 years,” Dr. Lee says. “The radiation oncologist can maximize tumor control while minimizing the toxicity of radiation therapy.”
Once testing provides a detailed analysis of a tumor, Dr. Lee may employ intensity-modulated radiation therapy (IMRT) or stereotactic body radiosurgery therapy (SBRT) as part of the precision medicine-guided course of treatment. Both forms of radiation therapy target tumors with superb accuracy. SBRT delivers a much lower dose of radiation to normal tissues surrounding a tumor and provides a much higher dose of radiation to the tumor, which means fewer clinic visits for patients.
The NewYork-Presbyterian Lawrence Hospital Cancer Center team regularly meets to discuss complex and unusual patient cases. Meetings can include oncologists, surgeons, pathologists, nurses, social workers, dietitians and other staff.
In addition to radiation therapy, the information gleaned through genetic testing informs other potential courses of treatment as well, whether chemotherapy, immunotherapy, surgery or different combinations of all of these approaches.
“We can then use our advanced technological capabilities to implement optimal treatments in a way that can positively impact patients’ lives quickly,” Dr. Lee explains.
“The NewYork-Presbyterian Lawrence Hospital Cancer Center offers a personalized, patient-centered approach with the vast expertise and resources of the NCI-designated Herbert Irving Comprehensive Cancer Center at Columbia University Irving Medical Center.”
— Henry J. Lee, MD, PhD, Director of Radiation Oncology at NYP Lawrence and Assistant Professor of Radiation Oncology at Columbia University Medical Center
The coordination of cancer care is mirrored in the close communications among NYP Lawrence clinicians at every level.
Dr. Wasserheit is a medical oncologist with more than two decades of experience. She is a dedicated and compassionate clinician who treats her patients with a highly personalized approach to care.
“All patients whose cases are challenging or raise questions are always presented at a tumor board: their X-rays, their pathology, as well as the medical, social and personal preferences, that may influence treatment recommendations,” Dr. Wasserheit says. “Team members include providers in radiation oncology, pathology, radiology, medical oncology, surgical oncology — all the disciplines — in addition to our supportive oncology providers: nurses, social workers, patient navigators, genetic counselors, physical therapists and the nutrition team. Based on the opinion of this expert multidisciplinary team, a personalized plan of treatment is recommended.”
“We also have disease-specific management teams,” Dr. Lee adds.
Further, NYP Lawrence oncologists participate in disease-specific case conferences with the clinician-researchers at Columbia for sarcomas, neurological tumors, skin cancers, and colorectal, hepatic, pancreatic, biliary, gynecologic, and head and neck cancers, in person or via teleconference.
Groundbreaking Clinical Trials
The benefits of precision medicine are also available to cancer patients at NYP Lawrence through more than 500 oncology clinical trials and a broad network of researchers affiliated with NYP.
Many of those trials are studying targeted treatment approaches that are especially important options for patients with advanced cancer, or in cases in which first- or second-line treatment has failed. NYP Lawrence’s integral role in clinical research further reduces logistical burdens on patients. For example, some of Dr. Wasserheit’s patients have received investigational drugs and were able to have their bloodwork or transfusions performed at NYP Lawrence instead of traveling into the city.
One of the key members of the Cancer Center team, Tabanfar works collaboratively with patients’ physicians and other clinical providers to determine which patients are candidates for genetic testing.
“Precision medicine is an exciting field. We are increasingly able to personalize an individual’s risk for cancer by evaluating how environmental factors, such as diet and exercise, work together with genetics to create or minimize that risk. This enables us to provide appropriate screening and even more effective treatments with fewer side effects.”
— Leyla Tabanfar, MS, CGC, genetic counselor for the NewYork-Presbyterian Lawrence Hospital Cancer Center
A Focus on the Patient
Concurrent with the use of advanced technologies, targeting therapies to patients’ and tumors’ genetic makeup, and participation in cutting-edge research, precision medicine also entails building a trust relationship with patients.
The Cancer Center has developed professional and caring clinical and support services teams, including members of the Infusion Unit. From left, back row, they are Makeba Washington, unit clerk; Kathleen Gutekunst, RN, oncology nurse navigator; Irina Escoffrey, RN, oncology nurse; Lyudmyla Kedyk, RN, oncology nurse; and Theresa Brady, RN, oncology nurse. Front row: Katherine Andersen, RN, oncology nurse educator; and Rowena Manabat, RN, oncology nurse.
“Patients certainly feel much more in control of their situation when they share decision-making with their physicians — when their doctors take into account the patients’ preferences and values, communicate what they know, and discuss treatment approaches that are best suited for the patient,” Dr. Lee says.
That commitment to communication enables physicians at the Cancer Center to optimize personalized care by understanding even more completely the focus of their efforts: the patient.
“In terms of precision medicine, patients hold all the answers to how we should treat them,” Dr. Lee says. “The job of the physician is to get those answers from the patient. Then the job of the team is to make sure that the right care, by the right team, is delivered to the patient at a time and location that are also right for the patient.”
For information about cancer care at NewYork-Presbyterian Lawrence Hospital, visit https://www.nyp.org/lawrence/services/cancer-center.