New Depths, New Heights

New Depths

Precision Medicine: Tailoring Treatments to Targets

In May 2017, the U.S. Food and Drug Administration made a paradigm-shifting approval, permitting the immunotherapy drug pembrolizumab to be used to treat patients with solid tumors containing a DNA repair defect called microsatellite instability (MSI) — regardless of the origin of the tumor. It was the first "tumor agnostic" approval ever, with the indication being specific to a molecular marker rather than a tumor site.

The game-changing approval is another milestone in the evolving field of precision medicine, whereby specific targetable genes in patients are identified and therapy is tailored to that person's genes.

Use of genetic and molecular information about a patient's tumor has become part of routine oncologic care. "Precision medicine gives us deeper insights into the biology of the tumor and enables us to understand the mechanisms driving the specific tumor," explains Minaxi Jhawer, MD, chief of hematology/oncology at Englewood Health. "By precisely targeting these markers and personalizing patient care, we are achieving dramatically better results for our patients with cancer than ever before."

Testing for Markers

Not all patients with a similar stage of breast or colon cancer are biologically or clinically the same. Some may be at high risk for recurrence, and others at low risk. Identifying markers to differentiate these patients helps with prognostication. For example, since the OncotypeDX test was introduced several years ago to determine if a patient with breast cancer needs chemotherapy, Englewood Health has made it a standard part of care for appropriate patients with breast cancer. The test gives the team the ability to understand the biology of a patient's specific tumor and risk stratify the patients. Low-risk patients may be spared chemotherapy, while the high-risk patients are given aggressive treatment modalities.

"We have always been ahead of the curve in identifying the best prognostic indicators for our patients," notes Englewood Health pathologist Ana Burga, MD. "Besides breast cancer, we routinely analyze colorectal cancer tumors to identify patients who have a high microsatellite instability tumor," she adds, in reference to cancer cells with a large number of a genetic mutation that results in an inability to correct mistakes when DNA is copied in the cell. "These cancers could be genetically driven and associated with Lynch syndrome [a hereditary cancer syndrome] or be sporadic. Nevertheless these patients are known to benefit significantly with immunotherapy drugs."

Today, genomic profiling is performed for patients with all stages of gastric, colorectal, lung, nasopharyngeal, endometrial, head/neck, anal, breast, and prostate cancers, melanoma, glioblastoma, and gastrointestinal stromal tumors, since targeted therapies have been developed for patients with these cancers who have certain biomarkers. Examples of genomic markers include:

• HER2 testing in gastric, colorectal, and breast cancers (as HER2-amplified tumors will respond well to drugs like trastuzumab).
• MSI in colorectal and endometrial cancers.
• ALK in lung cancer (which can be treated with crizotinib).
• BRAF in melanoma (a target of numerous melanoma medications).
• p16 as an indicator of human papillomavirus status in patients with head and neck and anal cancers.

Patients with advanced cancers and those whose tumors develop resistance to treatment may undergo even more expansive profiling for a wider panel of markers. This helps identify established targets for therapy as well as therapies being tested in clinical trials, giving patients the best overall options. The results of all testing are presented and discussed at the cancer center's cancer conferences, where multidisciplinary cancer care teams pool their input to determine the best treatment for each patient.

Influence Beyond Our Cancer Center

The expertise of Englewood Health's oncology professionals also extends beyond the hospital's walls. Dr. Jhawer serves on the Clinical Practice Guidelines Committee of the American Society of Clinical Oncology, which sets standard guidelines for cancer treatment and provides education and resources to oncologists across the world. And Dr. Burga is the cancer center's physician liaison to the Commission on Cancer, a multidisciplinary program of the American College of Surgeons and the cancer center's accrediting body.

New Depths

Cancer Prevention and Control: Prostate, Lung, and Colorectal Cancer Screening

An ounce of prevention is worth a pound of cure. For cancer, finding a tumor early — when it is most curable — is the next best thing to prevention. In recent years, Englewood Health has made a concerted effort to promote early detection in cancer, including prostate, lung, and colorectal cancers.

Prostate Cancer Screening

Prostate cancer screening has been controversial due to the limited specificity of prostate specific antigen (PSA) testing. Since the FDA approval of PSA for screening in 1994, death from prostate cancer has markedly decreased, but concerns have been raised about overdetection and overtreatment of low-grade disease. Subsequent discoveries and advancements have improved care and treatment for patients, with an emphasis on shared and individualized decision making.

Screening advancements have resulted in a decreasing number of unnecessary biopsies. In addition to PSA, there are now reflex tests available such as free PSA, PHI, and 4K score to better risk-stratify patients. Multiparametric MRI (mpMRI) has also played a tremendous role by improving diagnostic accuracy over the traditional methods and by reducing the number of unnecessary biopsies. The technology, called MRI/ultrasound fusion-guided prostate biopsy, was introduced at Englewood Health in 2017. It is a two-step process where a patient first undergoes mpMRI of the prostate. A radiologist then evaluates the images and identifies and marks any suspicious areas for further evaluation. The urologist then fuses the images with real-time ultrasound images, producing 3D images of the suspicious areas that are then targeted during the biopsy.

"Another exciting advancement is the introduction of genomic biomarkers and a number of genomic tools available that have improved detection, prognosis, and risk stratification," says Mazyar Ghanaat, MD, program director of urologic oncology. "Among these tools are newer types of tests to help identify patients who require prostate biopsy, help with management of patients with prior negative biopsies, and help improve prostate cancer risk stratification. Other biomarkers can help in the management of metastatic prostate cancer by predicting resistance or response to therapy. We are hopeful that ongoing advancements and clinical trials in prostate cancer, the most common cancer type in men in the United States, will help improve screening, diagnosis, and treatment; minimize overdiagnosis and overtreatment; and maximize survival."

Lung Cancer Screening

For people at increased risk of lung cancer, Englewood Health offers low-dose CT scans. Studies have shown that low-dose computed tomography scanning can help find small lung cancers. In fact, the landmark National Lung Cancer Screening Trial demonstrated that the use of this test in high-risk populations reduces cancer deaths by 20 percent.

"Prior to the introduction of this important tool, physicians had little to offer for the early detection of lung cancer," says Mark Shapiro, MD, chief of radiology. "We began performing low-dose CT scans for lung cancer in 2014, and have since performed more than 1,100 scans for at-risk smokers and former smokers. Ten cancers were diagnosed." To make the program a success, Englewood Health has targeted the identification of high-risk patients in primary care offices, followed up with screened patients for repeat scans or other additional tests, and upgraded CT and scanner equipment to optimize dose and radiation exposure.

The time between detecting a suspicious finding on a CT scan and starting treatment for lung cancer is relatively short at Englewood Health: just two to three weeks — much faster than most hospitals' lung cancer screening programs. Moreover, a dedicated navigator helps patients coordinate all aspects of their care, from diagnosis through treatment and survivorship. The goal is for patients to see all members of their multidisciplinary team on the same day to discuss their treatment.

The benefits of this screening are predicated on adhering to evidence-based criteria and guidelines. In recognition of responsible use of this technology for lung cancer screening, Englewood Health was named a Screening Center of Excellence by the Lung Cancer Alliance in 2017.

Colorectal Cancer Screening

While colorectal cancer screening with colonoscopy is generally advised to begin at age 45 and occur every ten years, people with an increased colorectal cancer risk due to heredity (such as Lynch syndrome or polyposis) or personal medical history (such as inflammatory bowel disease) may need to start this screening earlier and have it more frequently — as often as every one to two years in some cases. Englewood Health's cancer specialists assess each patient's risk and, working with the team in the Cancer Risk Assessment and Genetic Counseling Program, tailor an individualized plan of care. Colorectal cancer can often be prevented by removing potentially precancerous polyps before they have the opportunity to progress to cancer, making colonoscopy a proven technique for cancer prevention.

Englewood Health also responds to the unique needs of the large Asian population in Bergen County. Immigrants from Korea, Japan, and parts of China have an elevated risk of gastric cancer and may benefit from screening endoscopy. The good news is that they know they need screening. "Screening endoscopy is standard in these countries, so people who move here from those nations expect it when they get here," explains gastroenterologist Mitchell Spinnell, MD. "Some of them used to travel back and forth to Korea to get their screening, and now they know they can have it here."

New Depths

Unleashing the Immune System's Power to Fight Cancer

Immunotherapy — boosting the power of the immune system against cancer — has transformed the landscape of cancer treatment, becoming the fifth pillar of cancer therapy (in addition to surgery, chemotherapy, radiation therapy, and targeted therapies). Englewood Health has experience offering these novel therapies for patients with various types of cancer and is exploring new ways to use them more effectively.

Over the last few years, multiple immunotherapy drugs have been approved by the U.S. Food and Drug Administration — ranging from nivolumab and ipilimumab for melanoma, to pembrolizumab, atezolizumab, and durvalumab for lung and bladder cancers, among others. In addition, most of these medications have been subsequently approved for other cancer indications, making immunotherapy an option today for more people with advanced cancer.

"For some patients, immunotherapy has been revolutionary," asserts medical oncologist Brian Kim, MD. "There are patients with stage IV melanoma, for whom long-term survival was once unheard of, who can now expect to live five to ten years with immunotherapy." Similar advances have been observed for patients with advanced bladder cancer. No new drugs were approved for bladder cancer for 30 years, but five immunotherapy agents were FDA approved for this disease over the last few years alone. Patients with metastatic lung cancer, who once received prognoses of 12–18 months, are now living longer without disease progression while receiving immunotherapy.

Side effects remain a concern, but they have generated insights into new ways to use these therapies. Dr. Kim describes a patient with advanced lung cancer who needed to stop immunotherapy due to side effects, but has maintained remission for two years even without this treatment — indicating that sustained benefit may be achieved in some patients even after treatment is stopped. "We've had lots of success stories," adds Dr. Kim.

Englewood Health investigators are evaluating new ways to use immunotherapy in people with autoimmune diseases, such as Crohn's disease or lupus, who take medications to suppress their overactive immune systems. Many immunotherapies work by blocking proteins cancer cells use to evade detection by the immune system, unleashing the power of immune cells to find and kill cancer cells. Englewood Health doctors are identifying other medications to give these patients to make it safer for them to receive cancer immunotherapy. "We're trying to learn how to specifically suppress the autoimmune disorder while boosting the cancer-fighting effects of immunotherapy," notes medical oncologist Maxwell Janosky, MD.

Areas for Further Development

Despite the success of immunotherapy, not everyone responds, and some patients who initially do well eventually relapse. This remains an area of investigation: identifying factors that distinguish responders from nonresponders so doctors can optimize treatment and determine who is most likely to benefit. Englewood Health is conducting several immunotherapy clinical trials, including those evaluating immunotherapy drugs in combination with chemotherapy drugs to see if the effectiveness of treatment can be further enhanced.

New Depths

Cancer Risk Assessment and Genetic Counseling

Englewood Health has a dedicated Cancer Risk Assessment and Genetic Counseling Program for people with an increased risk of cancer due to hereditary factors, personal medical history, or other risk factors. What sets the program apart from many others is its staff of advanced practice nurses in genetics (APNG), certified through the American Nurses Credentialing Center. There are fewer than 60 such professionals in the country, and the three at Englewood Health make up most of those in New Jersey. The Commission on Cancer has commended the program at Englewood Health for Best Practices.

The advanced genetics nurses not only provide the program's services, but also participate as active members of the cancer center's multidisciplinary conferences — presenting patients' genetic test results and identifying those who should be recommended for a consultation. "In most hospitals, genetic counseling is a separate entity, but at Englewood Health, we are part and parcel of each patient's team," notes Rosalyn Stahl, MD, associate chief of pathology, who leads the program.

Program's Growth Over 15 Years

The Cancer Risk Assessment and Genetic Counseling Program was launched in 2003 to identify patients at elevated risk for breast and ovarian cancers. Since then, it has grown to include people at increased risk of pancreatic, colorectal, endometrial, stomach, and lung cancers. Along the way, many more cancer-related genetic mutations have been identified, so even people who have already been tested may consider being retested every few years as new mutations are pinpointed.

All patients diagnosed with breast cancer are now screened for genetic risk and referred to the program if necessary. In addition, patients are advised to consider a consultation if they were diagnosed with cancer before age 50 or have multiple close family members diagnosed with cancer before age 50; were diagnosed with more than one cancer; and/or have three or more close family members with different types of cancer.

Evaluation of Genetic and Environmental Risks

Despite the known contribution of genetics to cancer, most cancers arise sporadically. "Ninety percent of cancers are not hereditary," explains Patricia Mazzola, APNG, AGN-BC, the program's coordinator. She and the team, therefore, take into account other factors when evaluating a patient, such as certain environmental and lifestyle factors. The program's services include:

• Assessment of personal and family medical history.
• Genetic testing for multiple genes at the same time, if the team recommends it and the patient desires it.
• Discussion of genetic test results and their implications.
• Individualized recommendations about ways patients can reduce their risk of cancer and about routine screening tests, following guidelines set forth by groups such as the National Comprehensive Cancer Network and the American College of Radiology. For example, patients with a family history of breast cancer may be advised to have mammograms at an earlier age, interspersed with periodic breast ultrasound scans or breast MRI.

The team prides itself on being accessible and seeing patients quickly, sometimes the same day as someone has been diagnosed with cancer. The results of their consultations can have an important impact on a patient's ultimate treatment plan. "We work closely to obtain all the information we can before a decision is made about a patient's surgery, collaborating with pathologists, surgeons, and radiologists," says Mazzola. "We try to see patients during the same visit as their biopsy and help them navigate the process, so they know what they need to do next."

New Depths

Molecular Aspects of Breast and Colorectal Cancer: Joint Efforts with the National Cancer Institute

Englewood Health is combining its clinical expertise with the basic science acumen of the National Cancer Institute (NCI) to pursue several avenues of research delving into the molecular aspects of breast and colorectal cancer. Thomas Ried, MD, who leads the NCI's Cancer Genomics Section, knew about Englewood Health's strengths in this area and approached the medical center in 2014 about collaborating. Here are some projects now underway:

Clonal Instability in Noninvasive Breast Cancer

Findings of ductal carcinoma in situ (DCIS) have risen in incidence with refinements in mammography. Some DCIS will progress to invasive breast cancer and some will not. "The challenge is, we have no means of separating the bad guys from the others," explains Miguel A. Sanchez, MD, chief of pathology at Englewood Health and the medical director of The Leslie Simon Breast Care and Cytodiagnosis Center, who is spearheading the joint initiative with the NCI, together with pathologist Jausheng Tzeng, MD, also from Englewood Health. As a result, all women with DCIS are usually treated with surgery, and sometimes with radiation therapy and/or hormonal therapy — all of which may cause side effects.

In this research project, investigators are analyzing DNA from DCIS samples from patients and correlating the findings with clinical outcomes. The goal: to identify genetic mutations that can differentiate aggressive DCIS from DCIS that is likely to remain dormant. Such information could spare some women from unnecessary surgery and radiation therapy.

Improving Colorectal Cancer Screening in Inflammatory Bowel Disease

People with inflammatory bowel disease (IBD), such as ulcerative colitis and Crohn's disease, have an increased risk of colorectal cancer and typically undergo colonoscopy every one to two years, with multiple biopsies done to analyze tissue for premalignant changes. However, pathological analysis may not be entirely accurate: it can be difficult to distinguish premalignant changes from inflamed bowel. Analysis of DNA, the focus of this project, may be a more valid tool. "If you perform DNA analysis of colonic mucosa, you can see molecular changes that precede pathological changes and predict colorectal cancer development," says Dr. Sanchez.

Pathologist Daniela Hirsch, MD, a collaborator of Dr. Ried, came to the NCI in fall 2018 from the University of Heidelberg to lead this project in cooperation with the Englewood IBD team. The project involves performing DNA analysis on previously collected colon biopsy samples from 300 IBD patients and correlating the results with their clinical information. If predictive molecular markers can be confirmed, then the use of DNA analysis to predict colorectal cancer in people with IBD could prove more accurate than current means. It could also shorten the length of time to complete a colonoscopy because fewer tissue samples are required.

Predicting response to presurgical rectal cancer therapies

Chemotherapy and radiation therapy are often given to patients with rectal cancer before surgery to shrink the cancer, but not all patients respond — and many experience uncomfortable side effects. Dr. Ried is conducting "single cell culture analysis" to identify genomic markers distinguishing responders from nonresponders. With this technique, tumors can be grown in a laboratory from a single cell in culture and analyzed for mutations. Dr. Ried, Dr. Sanchez, and the colorectal cancer team plan to compare the results of the analysis between responders and nonresponders to find markers predictive of a response to presurgical treatment. If successful, this research would help guide physicians and spare some patients from therapies that would be ineffective for them.

New Depths

Patient Blood Management and Bloodless Surgery

For nearly a quarter of a century, Englewood Health has maintained a progressive approach to patient blood management. Through the internationally recognized Institute for Patient Blood Management and Bloodless Medicine and Surgery, established in 1994, the hospital offers safe and effective techniques performed without the transfusion of blood from a donor. Bloodless medicine and surgery can reduce the risks of blood transfusions (including infections and other complications), improve patient outcomes, and respect the needs of patients for whom blood transfusion is not an option (such as Jehovah's Witnesses). Englewood Health became the first hospital in the country to use patient blood management as a standard of care for all patients.

Englewood Health's bloodless medicine experts are now applying the knowledge they have learned to employ bloodless surgical techniques for patients with cancer, including complex procedures that other hospitals refuse to perform without transfusions. Moreover, the use of bloodless medicine in people who refuse blood transfusions for religious reasons or personal preferences is yielding insights that can improve cancer care for patients everywhere.

Combating Cancer's Devastation on the Blood Supply

Bloodless medicine techniques have been refined in people planning for elective surgeries like joint replacements. But cancer presents its own set of challenges. Its treatment, and sometimes the disease itself, can devastate the blood supply, causing white and red blood cell counts and platelets to plummet, as well as levels of iron and other building blocks of blood. At Englewood Health, patient blood management strategies are utilized before, during, and after transfusion-free cancer surgeries.

Preoperatively, patients may receive erythropoietin and iron to raise red cell counts, combating anemia.

During surgery, patients may undergo hemodilution (removing blood from the patient at the start of surgery, giving them fluids to maintain blood pressure, and then returning their blood at the end of surgery), or cell salvage (collecting and filtering blood lost during the operation and returning it to the patient through a closed circuit).

Postoperatively, erythropoietin and iron may be given, and blood draws minimized (using smaller pediatric tubes).

Complex Transfusion-Free Surgery

Nimesh Nagarsheth, MD, chief of gynecologic oncology and director of robotic surgery, has performed complex bloodless procedures for patients who were turned away elsewhere. One was a 52-year-old Jehovah's Witness with a 28-pound uterine leiomyosarcoma. Despite the size of the tumor plus the patient's multiple other medical problems, Dr. Nagarsheth and his colleagues were able to support her before and after surgery and use cell salvage during the procedure to remove the tumor.

"We frequently see patients who have been told by experts at major institutions that they couldn't help them," says Dr. Nagarsheth. "Then they have a conversation with us and are able to receive some form of treatment that no one else offered them. Patients come to us from across the country and around the world, even though there are plenty of other hospitals between their homes and here where they could have stopped."

A Better Outcome for All Patients

Englewood Health's success with patient blood management is so strong that virtually all surgeries at the hospital are now performed without transfusions, and for good reason: the hospital stay is typically shorter, patients recover more quickly, and there is a lower risk of complications. In fact, research shows that many patients are receiving blood transfusions when they don't all need them. "Why use a resource we don't have to use, especially when that resource can sometimes harm the patient?" notes Sherri Ozawa, RN, clinical director of the bloodless medicine institute. "Regardless of what patients want, we try to avoid transfusions because we know that's better. We were the mother ship for this movement."

New Depths

Precision Therapies for Neurological Cancers

Tumors of the brain and spinal cord can be challenging to treat successfully. They may be inoperable. The blood-brain barrier prevents many large molecular anticancer medications from crossing into the brain to reach tumors. Bathing the brain with whole brain radiation can cause side effects and cannot be repeated if the tumor comes back. And most malignant brain tumors eventually develop resistance to therapy, if they ever respond at all.

At Englewood Health, neurosurgeons and neuro-oncologists are finding more effective ways to circumvent these obstacles to improve the care of patients with brain and spinal cord tumors, as well as those with cancers of the peripheral nervous system. One of those approaches is stereotactic radiosurgery (SRS), which delivers highly focused beams of radiation directly to tumors while sparing nearby healthy central nervous system tissue from radiation exposure. Using the hospital's TrueBeam^® Radiotherapy System, doctors aim a single beam of high-intensity radiation at a patient's tumor, and they can go home the same day. Sometimes larger tumors require up to three to five treatment "fractions" over several days.

"SRS treatment is done once on an outpatient basis. There's minimal radiation to the normal brain, and it often can be repeated if the cancer returns," says Englewood Health neurosurgeon Kevin Yao, MD. "With traditional whole-brain treatment, you can't repeat this type of radiation if the tumor survives or returns." Moreover, unlike Gamma Knife^® radiosurgery, which requires patients to have a rigid frame screwed into the skull for rigid fixation SRS, patients receiving SRS using the TrueBeam approach wear a thermoplastic form-fitting mask that allows the treatment team to make adjustments for the patient and maintain comfort.

Minimally Invasive Neurosurgery

For those whose tumors are surgically accessible, Englewood Health's neurosurgeons rely on the hospital's expertise in bloodless medicine and patient blood management to operate with as little blood loss as possible. They have become known for performing large operations that other surgeons have turned away due to concerns about excessive blood loss, completing these procedures safely. The team is also proficient with "awake" surgery for patients with tumors near vital areas of the brain responsible for speech and movement, performing surgery guided by the patient's responses during the operation. "We've developed a targeted and elegant way to remove tumors that might otherwise be challenging to resect," notes Dr. Yao.

Customizing Chemotherapy

Treatment with the drug temozolomide and radiation therapy is a standard approach for patients with glioblastoma multiforme, the most aggressive brain tumor, but not all patients respond well to therapy. Patients with certain biomarkers are more likely to fare better than those without those markers. At Englewood Health, all patients with brain tumors have their cancers molecularly profiled for biomarkers that may indicate whether they are candidates for this treatment. Those deemed not to be candidates bypass what would likely be an ineffective therapy, so the treatment team can immediately move forward with more promising treatment, such as the drug bevacizumab (Avastin^®) or Novocure^™, a cap which uses electrical fields of different frequencies to treat brain tumors.

Clinical Trial Opportunities

For patients who do not respond well to standard therapies or for whom standard therapies are not feasible, the neuro-oncology team offers clinical trials of innovative approaches. For many people with nervous system cancers, clinical trials offer the most hope for extending life. Englewood Health's team evaluates all patients with nervous system cancers to determine if they are eligible to receive a promising investigational treatment.

Patient Stories

Stephen Swiderski, a World Traveler, Faces a Formidable Journey Through Bile Duct Cancer

Twenty countries in 20 years is more than most people can claim as a travel history, but for Stephen Swiderski, journeys are a passion. Two years ago, he did a 15-city trip across Italy over six weeks. When pressed, he'll admit that his favorite trip — the place that lived atop his bucket list, unchecked for far too long — is the Great Wall of China. It did not disappoint when he finally made the trip across the wall.

Amid these journeys was one he never expected to go on: a diagnosis of stage III cholangiocarcinoma, or bile duct cancer.

"The diagnosis really took me for a loop, and it took everyone else with me," Swiderski says.

It wasn't long before he was in conversations with his doctors about a treatment plan consisting of an eight-hour surgery followed by 28 days of radiation.

"I was going to fight it with all I had in me," he says. "This was something that physically and emotionally I could not succumb to. There were people that I just couldn't leave and that is what gave me the strength to say, ‘Steve, you're going to fight this thing tooth and nail.'"

Swiderski explained that he is still amazed by his doctors' abilities to take their respective passions and use them to save the lives of their patients. His surgeon, Steven Brower, MD, was a particularly strong guiding light throughout treatment. "Dr. Brower dismisses this as part of his job, but it is so much more than that. The same goes for the nurses that gave me so much of their time and were so compassionate with me. Even the assistants who came in to change the bed linen were caring and empathetic," Swiderski says.

The feeling is mutual. His medical oncologist, Minaxi Jhawer, MD, says, "It was such a pleasure to take care of Stephen. He always had a smile and positive attitude. We were able to navigate through the chemotherapy without any issues. I feel proud to have been part of his team, as we worked with the physicians, the patient navigator, nutritionist, and other staff to get Stephen through his care."

Now that he is on the other side of this cancer, he plans on returning to the life that he knows and loves. He's already set plans for trips to Portugal, Spain, and Malta. Swiderski found that when you finish cancer treatment, you have to regain your life — and return to it a smarter, wiser, and more aware person.

"And I can't say enough about Englewood Health. You're not just a number there. You're a person, you're a face, you're Steve."

Patient Stories

Mary Ann Fernandez, Yogi Mom of Three, Faces Breast Cancer with an Upbeat Attitude and Creative Expression

The five basic principles of yoga are exercise, breathing, relaxation, diet, and meditation. Being a yoga instructor herself, Mary Ann Fernandez was probably as mentally and physically resilient to face cancer as can be hoped. That didn't make it any easier, however, when she was diagnosed with breast cancer in August of 2015.

"I remember when they said the words, ‘breast cancer,' it all became fuzzy. I just collapsed because I didn't anticipate this being a big deal — I even had my youngest son in the waiting room. I had to walk out and look at him," Fernandez says.

A mother of three and the owner of a brand-new yoga studio, Fernandez was in great health at the time of her diagnosis, so the news came as that much more of a surprise to her and her family.

"Everything moved really quickly after that. I met my surgeon, Dr. [V. Merle] McIntosh, had more MRIs and testing done and began chemotherapy with my oncologist Dr. [Jill] Morrison," Fernandez says.

She was initially hesitant to undergo treatment, wondering if there was a holistic alternative she could explore rather than surgery and chemotherapy. "Ultimately, I was like, ‘I have three kids. I have to do treatment. I have to stick around,'" she says.

Fernandez' relentless optimism is what carried her through cancer treatment. At no point did she consider the possibility that she would not be OK in the end. She never lost her positive spirit or her sense of fun.

"I had a little project going on. I decided each day at chemotherapy was a theme, dressed up and took pictures. One day was The Matrix — I dressed up and had the blue cupcake and the red cupcake. Another was IV pole dancing — I came in a bikini and fur boots. If I had to be there for three hours, I was going to have fun," Fernandez says.

"Mary Ann was always so upbeat and positive about getting through her treatments and beating this," says Dr. McIntosh. "She was an inspiration and continues to be, as she works hard to motivate others to take care of themselves and to have an optimistic outlook."

Today, Fernandez is cancer free and back to doing what she loves. She teaches yoga, not only in her studio, but also at the Graf Center for Integrative Medicine at Englewood Health. She donates her time to Graf Center; she felt it was important to give back to the place that helped her through this incredibly tough time.

"I was in the best hands I can imagine at Englewood Health. I'm so happy I choose to go there."

Patient Stories

Lawrence D'Ercole Undergoes Pioneering Treatment for Lung Cancer

"I've been married to my sweetheart, Janet, for 59 years. We have three sons, three daughters-in-law, and nine grandchildren — all I can say is I'm so happy to still be here to see them," says Lawrence D'Ercole. He made history for being the first patient in New Jersey and one of the first in the country to undergo a new kind of radiation therapy for lung cancer following its FDA approval in April 2018.

The initial symptoms were mild enough — a little weight loss and a cough. So, when he was diagnosed with stage I lung cancer, it came as all the more of a shock to him and his family. "They did a CAT scan and found a nodule on my upper left lung. The patient coordinator at Englewood Health recommended I see Dr. Dubin," D'Ercole says.

Unbeknownst to D'Ercole, David Dubin, MD, chief of radiation oncology, and Michael Speiser, PhD, chief physicist, had just finished establishing stereotactic body radiation therapy (SBRT) with Varian Calypso^® Anchored Beacon^® transponders at The Lefcourt Family Cancer Treatment and Wellness Center.

Treating lung cancer with radiation therapy presents challenges. Ideal radiation treatment would target only the exact area of the tumor and no surrounding healthy tissue, but tumors in the lungs are constantly shifting position as the patient breathes. This motion typically requires larger treatment areas to ensure the moving tumor receives the full treatment. SBRT with Varian Calypso allows physicians to insert transponders — which act like a tiny GPS — around the tumor and track its whereabouts during radiation therapy 25 times a second. This makes the process much more precise and simultaneously spares the healthy tissue around the tumor.

"Mr. D'Ercole was a great candidate for this therapy," says Dr. Dubin. "Not only was his tumor location appropriate, but he happened to be great at holding and controlling his breath, taking in the same amount of air with each inhale. Like any treatment, this won't be appropriate in every case. Where the tumor is, the size of the patient, and the patient's lung capacity all play a role. But this treatment should be the standard, in my opinion, simply because of how accurate it is," Dr. Dubin says.

Two months after finishing radiation therapy, D'Ercole has started to feel better and has been spending a lot of time with his family. "I feel really lucky to have gotten to Englewood Health when I did. I've been there for other procedures and everyone is always great. I wouldn't go anywhere else for treatment," D'Ercole says.

Patient Stories

Wanda and Terri Faulk, Twin Sisters and Breast Cancer Survivors

For Wanda Faulk, the hardest part of cancer treatment came on the day she went to her salon to get her hair done for a wedding she was attending the following afternoon. During the appointment, her beautician suddenly emptied out the salon — telling everyone else to go get some food — then pulled Faulk aside and told her that her hair was falling out in chunks. This was a devastating blow to Faulk, who, before treatment, got her medium-length hair done almost every week.

"My mother and sister came to the salon. We cried together for a while, but then I told my beautician to just cut it and we went to Paterson to get a wig. The next day at the wedding, no one was the wiser," Faulk says.

Faulk had had leakage in her breast and was referred to V. Merle McIntosh, MD, chief of breast surgery. "Dr. McIntosh initially thought the leakage was the result of an infection, but upon further screening, she determined I did in fact have breast cancer," she says.

Faulk underwent chemotherapy and a mastectomy. On the day of her surgery, Dr. McIntosh walked with her to the operating room — a gesture that she remembers and appreciates to this day.

It's been several years since she finished cancer treatment at Englewood Health. As a long-time breast cancer survivor, she is the person to whom the women in her life turn when they are faced with the same diagnosis. She offers them the understanding that only a fellow woman who has contended with breast cancer can provide. Faulk imparts everything she learned during treatment, and in the years since.

"My treatment was exemplary. Everyone treated me well, from the ER nurses to the cafeteria staff. I refer everyone I know to Dr. McIntosh. My sister received treatment from Dr. McIntosh and so is my friend who was just diagnosed three months ago," Faulk says.

When Wanda Faulk's twin sister, Terri Faulk, was diagnosed just after her 50th birthday, she was shocked and frightened and experienced all the emotions one might expect — but she also had the benefit of having witnessed her sister go through it and survive.

"I'd like to think I was a good example of how not to fall apart. Terri had six-plus weeks of radiation done and, like was the case with me, the team at Englewood treated her extremely well. She made many friends there. They even played Marvin Gaye for her during treatment."

As for herself, Wanda Faulk has chosen not to grow out her hair since treatment. She keeps it short because, as she explains, she is a changed woman and isn't going back to who she was before.

Patient Stories

Keith Wilhemson — Schoolteacher, DJ, Family Man — Chooses Englewood for Rectal Cancer Treatment

"Initially I thought my stomach pains were a result of stress — my job can be pretty straining sometimes. Then around April 2018, I started noticing a change in my system. I was having to run to the bathroom more than is normal for me," Keith Wilhemson says.

He visited a doctor for his stomach issues and was told it was likely a bacterial infection.

"I was really lucky because before my doctor prescribed me the medicine, he decided to do a colonoscopy just in case. That's when they found the tumor," Wilhemson said.

He was diagnosed with locally advanced rectal cancer.

Three kids under the age of nine, a loving wife, a fulfilling career as a Paterson schoolteacher, and a side gig as a DJ were all more than enough reasons to keep Keith fighting through cancer treatment.

"My wife and I did our due diligence. We spoke to people at different hospitals, including one where we have some family friends working. Ultimately, we just felt very comfortable at Englewood Health. With them, everything was on the table. They were extremely open with us and that really gained our trust," Wilhemson says.

Wilhemson underwent nearly six weeks of radiation and chemotherapy. In September, Anna Serur, MD, chief of colorectal surgery, removed the tumor from his colon. He will soon undergo additional chemotherapy, the last portion of his treatment plan.

Wilhemson has healed well from surgery. The last couple months have been spent at home with his 8-year-old twin boys and his 2-year-old daughter. Wilhemson says this time has given him a renewed appreciation for all the stay-at-home parents out there.

"My experience with treatment has been really positive. When I went in for my infusions, I always messed around and joked with the team. They gave me a funny certificate when I finished my infusions. Now they're actually planning their Christmas party and are having it at the restaurant where I DJ on the weekends. I think I've made some friends that will last beyond treatment," Wilhemson says.

His surgeon, Dr. Serur, says, "We worked together with Keith and his family to provide the best long-term outcome and not to disrupt his life. Most importantly, we wanted Keith to continue smiling and doing what he loves best. We tailored his treatment without compromising his quality of life. He and his family went to Ireland in between his treatment and surgery, he took his kids to Disney World, and he celebrated his children's birthday parties with a bash."

Patient Stories

For Kevin Lee, Being Cancer Free Means a Return to His Life's Mission

Kevin Lee worked in the fine jewelry industry for 27 years before immigrating to the United States from South Korea in the mid-1980s. Since then, Lee has dealt with myriad health issues and has had a number of tumors detected in his body, prompting 10 surgeries.

In May of 2017, Lee received a diagnosis of bile duct cancer — one more in a long line of challenging news he's gotten from doctors over the years. At this point in his life, Lee was extremely hesitant at the thought of more treatment and another surgery.

His mindset changed when he met his surgeon, Steven Brower, MD, at The Lefcourt Family Cancer Treatment and Wellness Center at Englewood Health. Lee describes Dr. Brower as a humble man, with a confidence that put him at ease during some of the toughest moments.

After surgery, Lee decided to change up his lifestyle and begin a diet and exercise regimen that allowed him to gain strength.

In July of 2018, Lee came back to Englewood Health for a CT and MRI. When the results came back, he got his first piece of good news in a long time: the results were finally clean with no cancer cells remaining. These days Lee is a little less focused on his survival and is able to focus on the things he loves, including teaching gospel and studying for an upcoming mission trip to Kenya.

For Korean patients who seek care at Englewood Health, the Center for Korean Health and Wellness is an invaluable resource. The center, staffed by Korean-speaking staff, provides patient support and services to meet the health care needs of the growing Korean-American community in New Jersey, especially for patients who may have special language or cultural needs.

"Even for long-time residents of the United States, like Mr. Lee, it helps to have the support of people who know the language and culture," says Jina Kang, patient navigator in the Center for Korean Health and Wellness. The center also offers free education and support programs for the Korean community throughout the year, including many activities for health issues of particular concern to Koreans, such as hepatitis, liver cancer, and other cancers.

Patient Stories

Jason McMurtrie, Diagnosed with Pancreatic Neuroendocrine Cancer, Seeks Bloodless Surgery Expertise

Jason McMurtrie, a 47-year-old airport facility manager, and his wife, Amber, love to travel — they split their time between Pennsylvania and the island of Grenada. In the fall of 2017, McMurtrie received news that threw his life off course: He was diagnosed with a rare malignancy called a pancreatic neuroendocrine tumor, and he needed surgery to remove it.

"The first surgeon I saw, in Pittsburgh, said he always kept blood available for use in the operating room, but would make an exception for me," McMurtrie says. "I wanted to have surgery where blood is not considered an option."

This past spring, research and the recommendation of a friend led the McMurtries to the Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Health and pancreatic neuroendocrine tumor expert Steven Brower, MD, chief of surgical oncology and hepatobiliary surgery. Dr. Brower is also the medical director of The Lefcourt Family Cancer Treatment and Wellness Center at Englewood Health. Surgery on the pancreas is difficult to begin with, Dr. Brower says, but McMurtrie's tumor resided in an especially tricky spot — in the center of the organ atop a large artery and vein.

"With our radiologists' help, we mapped out a laparoscopic operation that could remove the growth and leave a normal, functioning pancreas instead of having to remove half or two-thirds of the organ," Dr. Brower says. "Removing that much of the pancreas would have increased Jason's risk of hormonal or digestive dysfunction."

McMurtrie was nervous about the surgery but ready to have it. "My anxiety stemmed from the thought of having my first major surgery," he says. "I spoke with Dr. Brower and his team about how I was feeling, and they were very caring. They sent an email of encouragement and confidence to let me know I was in good hands."

In September of 2018, Dr. Brower removed the tumor through several small incisions in McMurtrie's abdomen. The surgery went off without a hitch. McMurtrie didn't lose any blood, and the operating team did not have to perform an autotransfusion — recycling of a patient's blood back to him or her using a closed circuit — as they had prepared to do. After four nights in the hospital, he returned home to Pennsylvania. With the tumor gone, his future is bright.

"Going forward, I'll have a few more checkups, but Dr. Brower feels confident that chapter of my life is closed," McMurtrie says. "That makes me happy."

Patient Stories

Fourteen Weeks Pregnant, Carolina Antonelli Faces a Cancer Diagnosis and a Wrenching Decision

Love at first sight is a particularly illusive kind of magic, the existence of which has been debated for centuries. But if you ask Matthew Antonelli, he'll tell you he knows it to be real — because he it felt it the second he laid eyes on Carolina. He took one look at her curly head of hair and her bright smile and knew instantly that she was the one for him. It wasn't long before he got down on one knee and a proposed atop a snowy mountain.

"It was a fairytale. I found the right girl, we got married and then it gets even better — she's pregnant. But then it just goes downhill," he says.

Fourteen weeks into her pregnancy, Antonelli was diagnosed with cervical cancer. The couple faced a nearly impossible decision.

"We knew we wanted a family. We wanted this baby more than anything. It was a tough situation to accept," Antonelli says.

The choice of whether or not to terminate the pregnancy in the interest of her own health plagued the couple. They worried that following through with the pregnancy might endanger mother and baby, but terminating meant losing the possibility of a future with biological children.

In recent years, cervical cancer has become somewhat rare. It was, and still is, even rarer to have cervical cancer during a pregnancy.

"We had to perform a robotic pelvic lymphadenectomy during her second trimester to make sure the cancer hadn't spread to the lymph nodes," says Nimesh Nagarsheth, MD, director of gynecologic oncology and director of robotic surgery. "In all the world's literature we have, this was only the second time this procedure was performed. After confirming that the cancer hadn't spread, Carolina was able to choose to keep the pregnancy."

After her surgery, Antonelli underwent chemotherapy. "We did our research; we visited other hospitals. But nothing gave us the warm feeling we got at Englewood Health. They gave us the positive atmosphere and reassurance we needed," Mr. Antonelli says. He was at her side every day and, within a few months, a healthy baby girl was born.

"Angelina is the sweetest little girl. She's such a miracle. I'm so grateful to Englewood Health. Because of them, I have a beautiful family and a lot to look forward to," Antonelli says.

New Heights

Renovations and Expansion of Our Cancer Center

In 2013, our cancer care services were spread out, and our infrastructure was challenged to support our commitment to leading-edge care close to home. We identified a vision for the next few years that brought together existing and future talent, services, and technology in a single centralized location that would embody a patient-first philosophy.

This vision matured into a multiyear modernization project and strategy that has since elevated cancer care to a level that rivals the quality found at leading cancer centers across the nation. We have since added three additional floors in The Russell and Angelica Berrie Center for Humanistic Care dedicated to cancer and wellness services. The 185,000-square-foot facility now houses all cancer services and specialists in a single location, minimizing patient anxiety and making for a smooth, seamless transition from one area to another. This transformative project included The Wilson Kaplen Infusion Center, The Leslie Simon Breast Care and Cytodiagnosis Center, The Coe Radiation Oncology Center, Graf Center for Integrative Medicine, The Braverman Family Executive Wellness Program, and physician practices and offices, as well as The Taub Family Education Center and administrative space. As part of the breast center's renovation and expansion, we introduced spa-like amenities to create a therapeutic environment, as well as a new clinical floor plan to optimize patient flow. At the same time, advanced equipment such as 3D Mammography^™ (breast tomosynthesis) ensures that patients benefit from a high-tech, high-touch experience.

New Heights

Patient Navigation

Over the past three years, we have enhanced the care we provide to patients through a dedicated oncology patient navigation program. These patient navigators in The Cahn Family Cancer Care Companion Program serve as a patient's direct contact within The Lefcourt Family Cancer Treatment and Wellness Center and help coordinate the patient's care. They are critical to identifying patients' personal needs and creating a personalized care plan. Our patient navigators also help schedule appointments, provide information on community and hospital resources, and facilitate communication among a patient's care team members.

New Heights

Integrative Medicine

In 2015, thanks to the generous support of our friends Jennifer and David Graf, we opened the Graf Center for Integrative Medicine. The Zen-like center offers acupuncture, meditation, therapeutic massage, holistic nutritional counseling, and other evidence-based services focused on prevention, recovery, and support. Our cancer center team works closely with the Graf Center to provide services for patients undergoing cancer treatment. As integrative medicine has become more mainstream, it is important that such services are overseen by licensed or certified professionals and delivered in coordination with a patient's doctor. In 2017 alone, nearly 3,300 patients sought services at the Graf Center, and the average monthly volume has increased each year since it opened. Increasingly, the Graf Center is partnering with community and civic organizations to bring wellness services and education to more of our neighbors. In 2018, we welcomed Tracy Scheller, MD, MS, MBA, FACOG, as the new medical director of integrative medicine.

New Heights

Leading-Edge Technology

Over the past four years, Englewood Health has invested in advanced technology to aid in the diagnosis and treatment of cancer.

Central to our arsenal has been the acquisition and development of two Varian TrueBeam^® linear accelerators for external beam radiation therapy and radiosurgery. TrueBeam's state-of-the-art technology allows for safer and more efficient radiation therapy, offering seamless integration of patient imaging, motion management, and treatment. This results in more precise treatments in less time, while providing a more comfortable experience for patients. TrueBeam technology treats the affected area of the body with increased accuracy and precision, targeting cancer cells while minimizing damage to surrounding normal tissue.

"TrueBeam gives us the tools that we need to treat more complex cancer cases, unlocks treatment options for patients who otherwise may not be candidates for traditional radiotherapy, and offers unique benefits to patients with lung, head and neck, breast, and prostate cancer," says David Dubin, MD, chief of radiation oncology.

The advanced system delivers many forms of treatment, including image-guided radiotherapy (IGRT), image-guided radiosurgery (IGRS), intensity-modulated radiotherapy (IMRT), RapidArc^® radiotherapy, and gated RapidArc^®. Integrated motion management hardware and software accounts for even slight shifts of a patient's movements, allowing physicians to monitor the patient and tumor movement at all times. This helps ensure patients do not receive too high or too low a dose of radiation.

Englewood Health has been at the forefront of advanced radiosurgery for years. As an official reference site for Varian Medical Systems and other major medical companies, Englewood Health often employs radiation oncology to demonstrate to other institutions how even the most advanced techniques can be performed in a community hospital setting.

In 2018, we introduced lung stereotactic body radiation therapy (SBRT) with Varian Calypso^® Anchored Beacon^® transponders. As a result of our extensive experience with SBRT, the team at Englewood Health was the first center in New Jersey, and one of the first in the entire nation, to perform this advanced form of radiation therapy (see patient story on page 20). The Calypso system, which was cleared by the FDA in April 2018, is the only device on the market that delivers real-time, 3D tumor position information 25 times per second, improving confidence that the prescribed dose has been delivered to the tumor.

New Heights

Complex, Robotic Surgery

Our surgeons use minimally invasive approaches — robotic or laparoscopic surgery — to perform even the most complex surgeries, such as rectal cancer or ulcerative colitis surgery. Anna Serur, MD, joined Englewood Health in early 2017 as chief of colorectal surgery. Dr. Serur specializes in laparoscopic and robotic colorectal surgery, anorectal procedures and reoperative abdominal and pelvic surgery, including sphincter-sparing surgery and avoidance of permanent colostomy. These minimally invasive approaches use small incisions in combination with 3D high-definition imaging for enhanced vision and control, leading to a more precise and accurate procedure.

New Heights

Cancer Clinical Trials

The best management for any cancer patient is in a clinical trial, according to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines. To that end and as part of the cancer center's mission, physician-investigators are actively researching new treatment options for our patients through clinical trials. These trials are looking at new, innovative ways to diagnose and treat cancer in patients. In addition to offering new biological, targeted, and immunotherapy drugs, we are working with institutions such as the National Cancer Institute to study the biology of cancer cells and understand what drugs will be the most effective in fighting a patient's cancer.

Cancer Study		Patients Enrolled (2015-current)	Funding Received
NCI Cooperative Group Studies	S1403	2	$89,425
	S1007	5
	A221201	3
	E1412	1
	E2112	1
	S0931	1
	S1505	1
	B-51	2
	Prospect	2
	TNT Rectal	1
	S1406	2
	A041202	1
	BWEL	3
Korean Breast Registry		9	—
Rectal surveillance registry		3	—
Connect MDS		6	—
Magnify		2	$57,443
Pallas		11	$120,980
Celgene ABOUND		1	$38,898
My Plan		15	$21,700
Inform CLL		2	$9,050
Compleement		5	$36,240
Merck Breast		1	$37,675
Merck Keynote 185 MM		2	$67,150
BBI Pancreatic		1	$10,000
COMET		2	$8,950
Bayer Prostate		1	$22,400
Genentech Lung		3	$80,772
Ovario		1	$12,000
Total		89	$612,684

New Heights

Grand Rounds and Scientific Symposia

Beginning in October 2015, we began a monthly Cancer Center Grand Rounds series. Each month, we delve into a topic of interest to our cancer specialists and other healthcare professionals. Our own cancer center members have presented on clinical research and practice topics such as ductal carcinoma in situ, urological malignancies, medical marijuana and pain management, and radiation therapy advances. We have also welcomed esteemed colleagues from other institutions as guest speakers.

These academic sessions are held in The Taub Family Education Center, a suite of conference and seminar rooms built as part of our multiyear renovation and expansion project. The rooms are outfitted with multimedia capabilities to support the learning needs of our members.

Also in 2015, we held our inaugural Cancer Symposium. These continuing medical education programs, open to both our own members and community physicians, have highlighted scientific advancements in oncology and featured leading experts from national and international organizations.

2015 Cancer Symposium

Molecular Pathology in the Diagnosis and Treatment of Cancer

Guest Speakers

GERT AUER, MD, PHD
Professor, Cancer Proteomics
Karolinska Biomics Centre and Karolinska Institutet Karolinska University Hospital

KERSTIN HESELMEYER-HADDAD, PHD
Staff Scientist
National Cancer Institute

THOMAS RIED, MD
Chief, Section of Cancer Genomics
National Cancer Institute

2016 Cancer Symposium

Lung and Gastrointestinal Cancers: Screening and Treatment in High-Risk Populations

Guest Speakers

JAMES PARK, MD
Associate Professor of Medicine
NYU School of Medicine
Clinical Director of Hepatology
Co-Medical Director of Transplant Hepatology
Director of Asian Liver Health Program
Division of Gastroenterology, Department of Medicine
NYU Langone Medical Center

ALEX KAGEN, MD
Site Chair, Department of Radiology
Mount Sinai Roosevelt
Associate Professor of Radiology
Icahn School of Medicine at Mount Sinai

HOO GUEN CHUN, MD
Director of Comprehensive Cancer Institute
Seoul St. Mary's Hospital
Vice President of External Affairs and Collaborations
Seoul St. Mary's Hospital
Professor of Internal Medicine
Catholic University of Korea

2018 Cancer Symposium

Cancer Case Studies and Screening Guidelines

Outcomes

The Lefcourt Family Cancer Treatment and Wellness Center Cancer Registry

In an 18-month period (July 2016 through December 2017), there were 1,824 diagnosed and treated cases recorded in The Lefcourt Family Cancer Treatment and Wellness Center cancer registry. The top eight types of cancer at Englewood Hospital during this period were breast, lung and bronchus, colon excluding rectum, bladder, thyroid, Non-Hodgkin lymphoma, prostate, and pancreas.

Site Group	Total Cases
Oral Cavity and Pharynx	35
Tongue	9
Salivary Glands	4
Floor of Mouth	1
Gum and Other Mouth	5
Tonsil	8
Oropharynx	5
Hypopharynx	2
Other Oral Cavity and Pharynx	1
Digestive System	350
Esophagus	10
Stomach	31
Small Intestine	6
Colon Excluding Rectum	129
Rectum and Rectosigmoid	61
Anus, Anal Canal, and Anorectum	5
Liver and Intrahepatic Bile Duct	20
Gallbladder	4
Other Biliary	9
Pancreas	66
Peritoneum, Omentum, and Mesentery	9
Respiratory System	148
Nose, Nasal Cavity, and Middle Ear	2
Larynx	6
Lung and Bronchus	140
Soft Tissue	6
Soft Tissue (excluding heart)	6
Bones and Joints	1
Skin Excluding Basal and Squamous	53
Melanoma	50
Other Non-Epithelial Skin	3
Breast	618
Female Genital System	111
Cervix Uteri	10
Corpus and Uterus	68
Ovary	20
Vagina	1
Vulva	9
Other Female Genital Organs	3
Male Genital System	72
Prostate	68
Testis	4
Urinary System	102
Bladder	69
Kidney and Renal Pelvis	29
Ureter	3
Other Urinary Organs	1
Eye and Orbit	0
Brain and Other Nervous System	39
Brain	15
Cranial Nerve/Other Nervous System	24
Endocrine System	94
Thyroid	86
Other Endocrine Including Thymus	8
Lymphoma	89
Hodgkin Lymphoma	5
Non-Hodgkin Lymphoma	84
Myeloma	30
Leukemia	28
Lymphocytic Leukemia	14
Myeloid and Monocytic Leukemia	14
Mesothelioma	2
Kaposi Sarcoma	0
Miscellaneous	46
Total	1,824

Cancer Diagnoses

Select Cancer Site Groups

Digestive Cancers

Genitourinary Cancers

Gynecologic Cancers

Head and Neck Cancers

Blood Cancers