Health Quest is adding high-tech oncology capabilities and expanding its Supportive Care Medicine program so patients can receive comprehensive cancer care near their homes and families.
Ryan Swan, MD, surgical oncologist and hepatobiliary surgeon at Health Quest Medical Practice, P.C., and Caitlin O’Shaughnessy, NP, discuss a patient’s case.
As a case in point, Health Quest’s hepatobiliary program has made strides in providing treatments typically not found outside an academic medical center, offered by specialized oncologists working closely with radiologists and supportive care providers. The multidisciplinary program centers on Vassar Brothers Medical Center, the flagship hospital of Health Quest, and the Dyson Center for Cancer Care, long known for providing the latest oncology services to patients in the Mid-Hudson Valley.
Ryan Swan, MD, surgical oncologist and hepatobiliary surgeon at Health Quest Medical Practice, P.C., leads the hepatobiliary and pancreatic surgery team at Vassar Brothers Medical Center. His collaborative approach, paired with an extensive academic background — he is one of the few fellowship-trained hepatobiliary surgeons in the Mid-Hudson region — makes him an ideal leader in Health Quest’s mission to advance cancer care.
“Health Quest and Vassar Brothers Medical Center have a long tradition of providing outstanding cancer care in numerous specialties, such as breast, gastrointestinal and colorectal cancer,” Dr. Swan says. “As Director of Liver and Pancreas Surgery, I was brought here to enhance those areas. Vassar already has a strong structure and robust support in place for those programs, and my job is to move us forward. We have significantly increased our case complexity in terms of the liver and pancreas resections we undertake. Our hospital has a solid surgical tradition and excellent operative and ICU teams, so I was able to make those advances with confidence.”
Leading-edge Approaches to Complex Cases
Dr. Swan performs minimally invasive surgery to treat a broad range of complex hepatobiliary conditions, shattering the common perception of liver surgery as necessarily an onerous, open procedure.
“The discipline has really evolved in the past decade,” he says. “We can perform major resections through small incisions. Patients leave the hospital much sooner.”
Liver surgery poses unusual challenges and opportunities, Dr. Swan notes, because the liver is the only organ in the body that regenerates. Surgeons leverage that potential, while still proceeding cautiously to preserve the liver’s function of removing toxins from the body. This balance can direct their decision-making process. Dr. Swan illustrates:
Camilo G. Torres, MD, Medical Director for Radiation Oncology at Health Quest Medical Practice, P.C., assesses a patient during a consult.
“Colorectal metastasis of the liver was once considered unresectable if there was disease on both sides of the liver. As chemotherapy has improved, we’ve been able to shrink lesions and control the disease. We can then perform laparoscopic surgery to remove cancer from the less diseased side of the liver, then ask our radiology colleagues to ablate the veins supplying the other side of the organ, interrupting the blood supply to the cancer on that side. We take advantage of the liver’s unique ability to grow the side we want to leave in before we remove the side we want to take out, with the result that we can ensure the patient has a safe amount of remaining disease-free liver even before we undertake resection of the heavily diseased side.”
Another minimally invasive approach to liver surgery is microwave ablation, in which physicians use a needle to apply microwave energy into a tumor.
“This technology can be used to kill tumors that are otherwise unresectable, or tumors in patients who could not safely undergo liver resection, either through the skin using CT scan guidance or laparoscopically through small incisions,” Dr. Swan says. “Open surgery is rarely performed.”
Pancreatic cancer, often discovered past the window for surgical resection, has long challenged oncologists.
“Pancreatic cancer is a terrible disease,” Dr. Swan says. “With advances in chemotherapy and radiation therapy, more patients with locally advanced pancreas cancer are able to undergo surgical resection, with the expectation that they will enjoy a longer life than anything we could have hoped for even a decade ago.”
Vassar also offers surgical therapies for other pancreatic and bile duct conditions, including pancreatic cysts and chronic and acute pancreatitis.
“During my hepatobiliary fellowship, I treated a lot of benign disease,” Dr. Swan says. “Bile duct injuries can happen during cholecystectomy and may be devastating. They are complex to repair in a durable fashion. That’s one of the many specialties we have here that make a significant difference in a patient’s life.”
Some patients with acute and chronic pancreatitis should also consider Vassar, Dr. Swan says. While many patients have a brief attack of pancreatitis followed by successful gallbladder surgery, some require long-term hospitalization.
“I have a great deal of experience caring for those patients, and I enjoy working with them,” Dr. Swan says. “When you help someone back to a normal functioning level, it’s very gratifying. Sometimes that process can involve surgery, sometimes not. Patients may need a drainage procedure, for instance, which can often be performed by the radiologist using CT scan or the gastroenterologist with an endoscope. Guiding someone through that involves a high level of nuance.”
Mary L. Dunne, MD, Director of Supportive Care Medicine at Health Quest Medical Practice, P.C., discusses her supportive care medicine approach with a patient.
Dr. Swan also treats neuroendocrine tumors in the pancreas and other areas of the body, such as the small intestine and colon. Often, he says, these tumors spread to the liver.
“This is another disease that can grow in an indolent fashion, without the patient’s knowledge,” he says. “Some neuroendocrine tumors secrete chemicals that alert a physician to their presence, but their presentation can be confusing. They can release insulin and affect blood sugar levels, for instance, or the patient may experience flushing and rapid heart rate.”
“With symptoms such as these, we perform a chemical profile, which we use to determine a treatment plan. Some pancreatic neuroendocrine tumors may not do anything for years; others behave aggressively. We decide whether to use chemotherapy or surgery, which frequently removes all the disease and improves survival. When the disease has spread to the liver, we may be able to perform a partial resection. Or, if surgery is not an option, the interventional radiologist may use a liver-directed therapy, such as radiation beads, to control symptoms.”
A True Partnership: Surgical and Radiation Oncology
Surgery is only one tool physicians use to combat cancer. Health Quest Medical Practice, P.C., recently expanded its capabilities even further by bringing on board five long-standing radiation oncology specialists to the medical group — Edward Farhangi, MD, Thomas Mazzilli, MD, Dimitrios Papadopoulos, MD, Robert Smith, MD, and Camilo Torres, MD. Under the guidance of Dr. Torres, the Medical Director of the team, this group is advancing radiation therapy treatments and extending patients’ lives throughout the Mid-Hudson Valley.
Radiation therapy and consultative appointments typically take place at the Dyson Center for Cancer Care at Vassar, as well as the Fishkill Radiation Oncology Center in Fishkill, the Agarwal Radiation Oncology Center in Carmel and the Ulster Radiation Oncology Center in Kingston. In some locations, patients have the opportunity to conveniently see many providers under the same roof.
Camilo Torres, MD, works with a radiation therapist to begin treatment for a patient.
“A referring oncologist can make multiple appointments for patients at the Dyson Center,” Dr. Torres says. “Our electronic system allows us to obtain feedback or review progress notes very quickly, so we respond to their request for a consult efficiently. The oncologist can then review the consult notes and create a plan for the patient.”
Coordination is facilitated by nurse practitioners such as Caitlin O’Shaughnessy of Health Quest Medical Practice, P.C., who has expertise in treating complex diseases of the liver and pancreas. The availability of chemotherapy and radiation therapy in adjacent buildings provides patients with the benefits of streamlined care in a centralized setting.
“It’s comforting for referring providers to be able to tell patients all their needs will be met as a whole patient,” Dr. Torres says. “In addition to talented surgeons, we have excellent new radiation therapy equipment, so we can offer targeted and image-guided therapy. In medical oncology, we are offering new medications and protocols to deepen our understanding of how patients should be treated. They no longer need to travel to be part of an investigational protocol.”
Health Quest has systems in place to ensure this wide range of choices does not become overwhelming for patients. At the Dyson Center, patients participate in a carefully guided decision-making process so they can understand their options, including no treatment, single or combined therapies, and referral for a second opinion.
Among the radiation options available, the Dyson Center offers brachytherapy, intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT) and radium 223 therapy, depending on the location, type and extent of the cancer and the purpose of the treatment.
“Brachytherapy is a specialized treatment directed at a localized area,” Dr. Torres explains. “We place apparatuses inside the body to treat the tumors where they are. It’s very conformal, allowing us to give a high dose of radiation with excellent results.”
Radium 223 is delivered as an injection to patients with bone metastases from prostate cancer, he adds.
“We were the first in the region to offer that treatment,” he says. “We inject the radium once a month for six months, and it works really well. It’s been shown to increase overall survival.”
IMRT is a well-established therapy at which Health Quest Medical Practice’s experienced radiologists also excel. Using linear accelerators, they create what Dr. Torres describes as “conformal clouds of radiation” to encompass a tumor and spare surrounding tissue. A related, newer procedure, IGRT uses CT-quality imaging taken prior to the therapy to focus the radiation field. Matching the previous CT scan with a scan taken immediately before the procedure, the radiologist performs the treatment with great accuracy.
“We’re delivering treatment that has 5-millimeter margins,” Dr. Torres says. “It’s extremely precise, with few side effects to surrounding organs. Twenty years ago, we were giving doses of 6,000 centigray, whereas now we can deliver 7,900 to 8,000 centigray, which is a huge increase in radiation with fewer side effects than we had with the smaller dose.”
In an efficient partnership, radiation oncologists and surgical oncologists work closely to deliver intraoperative radiation during some surgeries.
“We’ve been part of the targeted intraoperative radiotherapy, or TARGIT, protocol,” Dr. Torres says. “It was initiated in Europe, and we were among the first to offer it in the United States. In breast cancer surgeries, it delivers a single dose of radiation into the cavity of the breast after a lumpectomy is performed. Five-year data suggest it is a feasible treatment model. Patients can avoid post-surgical radiation and instead receive a single dose at the time of surgery, for an incredible savings of time and money. There is talk of using intraoperative radiation for other organs, too.”
Ryan Swan, MD, Health Quest Medical Practice hepatobiliary and pancreatic surgeon
Health Quest also offers transarterial therapy as a method of direct radiotherapy or chemotherapy delivery.
“The interventional radiology team at Vassar Brothers Medical Center is also performing transarterial therapy to direct radioactive beads or chemotherapy into the liver,” Dr. Swan says. “That has really expanded our capabilities.”
Supportive Care for Patient and Family
The patient’s experience is at the heart of his or her cancer journey, and Health Quest Medical Practice’s supportive care program focuses comprehensively on that experience. Commonly known as palliative medicine, supportive care is now recognized as encompassing more than just pain management or end-of-life guidance. Instead, says Mary L. Dunne, MD, a supportive care medicine physician and Director of Supportive Care Medicine at Health Quest Medical Practice, the program is designed to sustain both patients and families throughout the course of the illness.
Dr. Dunne has guided the supportive care program since its inception as an inpatient palliative medicine program at Vassar Brothers Medical Center in 2001.
“To my knowledge, we were the first program of this kind between New York City and Buffalo,” she says. “We started a task force and recognized a lot of national momentum in the field of palliative care, which was broadening from end-of-life care to holistic care for any patient with serious illness.”
The Supportive Care Medicine program is newly housed on the third floor of the Dyson Center for Cancer Care, conveniently accessible to patients and providers. Clinicians are actively raising awareness in the community about their capabilities and reaching out to specialists throughout the Mid-Hudson Valley. The inpatient staff consists of four physicians and a nurse practitioner with backgrounds in emergency medicine, family medicine, internal medicine, geriatrics and critical care.
“People come to this work from very different places, often motivated by their personal experience in their practice,” Dr. Dunne says. “We draw on specialties as diverse as anesthesia and psychiatry.”
The outpatient staff consists of Dr. Dunne and a nurse practitioner, soon to be hired, who will bring competencies in healing touch, Reiki and nutrition, as well as traditional medicine. Treatments will be available to patients with a range of conditions.
Mary Dunne, MD, and Jack Keene, MD, collaborate on a supportive care medicine patient case.
“People with all types of cancer are eligible for supportive care,” Dr. Dunne says. “Those with a new diagnosis and an excellent prognosis may welcome the opportunity to optimize their coping and wellness strategies as they navigate treatment. Patients who are diagnosed with very advanced disease, on the other hand, may be ready to discuss transition to hospice. It’s an entire spectrum of care. Patients can elect to come on their own, or treating physicians may refer them.”
Recognizing that families also suffer pain, confusion and loss during a loved one’s illness, Supportive Care Medicine treats both groups, Dr. Dunne says.
“We focus on helping families understand illness and optimally support their loved one,” she says. “When you’re ill and vulnerable and fragile, everything is fraught with meaning. To be given a referral to a physician to treat something you don’t understand may be very alarming and difficult to accept. We partner with patients and their families to assist them when they face those types of circumstances.”
Much of the work of supportive care is communication — helping people understand their situation and choices and articulate their goals and values, while bridging gaps in understanding among specialty providers, patients and families.
“A great deal of what we do is communication support, bringing medical colleagues together to explain to patients and families where they are with their illness and helping them to be active in shared decision-making,” Dr. Dunne says. “Our mission is not to interrupt the relationships between patients and their primary care and specialty providers, but to provide an additional layer of care for people with complex needs and symptoms.”
Good Neighbors in the Mid-Hudson Valley
Health Quest’s expanded oncology program, now partnered with outpatient supportive care medicine, means patients may receive a higher level of cancer treatment locally, with their families nearby to provide more support, Dr. Swan says.
“It’s not merely that we find a cancer and remove it,” he says. “There is preoperative testing, counseling, chemotherapy and radiation therapy. Many of these are daily treatments. Friends and family may also undergo counseling, and the patient has easy access to his or her physician, nurse practitioners and nurse navigator.”
Health Quest’s locations throughout the Mid-Hudson and supportive care approach make this intimacy possible.
“We have a compassionate, cohesive team that offers cutting-edge therapy close to home,” Dr. Swan concludes. “It’s as simple as that. I honestly don’t think a patient will get better care anywhere else.”
For additional information, visit healthquest.org/cancer.