avera cancer institute

Summer 2014 Avera Cancer Institute 12

AVERA CANCER INSTITUTE IS PROVIDING INCREASED ACCESS TO QUALITY CANCER CARE

MANYLOCATIONS

AVERA RESEARCH TEAM IS REDEFINING PERSONALIZED CANCER CARE

ALCESTER COUPLE EXPERIENCECANCER CARE DONE DIFFERENTLY

GENOMIC MEDICINE

One Avera

– TIMES TWO

Supportof Avera

Summer 2014

CancerAveraInstitute

We’d like to introduce you to Avera Cancer Institute, and show you how cancer care is done differently at Avera.

You may be a cancer patient yourself. You may love someone who has cancer. Or, you want

to help prevent cancer in your own life and the lives of others. If you see yourself in one or more of the above, this magazine is designed for you!

Please take a few moments to read about preventive screenings, because cancer prevention begins with you. You’ll find articles about how to live well with cancer, plus stories of hope about real people at various stages along the journey. You’ll also read about some of the latest technology being used at Avera in the fight against cancer.

Whatever your walk of life, we want to share the hope that exists for today’s cancer patients, and the friends and families who love them.

Thanks for reading! Please visit Avera.org/cancer to learn more.

Tad Jacobs, DOChief Medical Officer, Avera Medical Group

Avera Cancer Institute Aberdeen 305 S. State St. Aberdeen, SD 57401605-622-5000

Avera Cancer Institute Marshall 300 S. Bruce St. Marshall, MN 56258507-532-9661

Avera Cancer Institute Mitchell 525 N. Foster Mitchell, SD 57301605-995-5756

Avera Cancer Institute Sioux Falls 1000 E. 23rd St. Sioux Falls, SD 57105605-322-3000

Avera Cancer Institute Yankton1115 W. Ninth St. Yankton, SD 57078605-668-8000

Avera St. Mary’s Hospital801 E. Sioux Pierre, SD 57501605-224-3100

ONE AVERA CANCER INSTITUTE. SIX MAJOR LOCATIONS.DEAR READERS,

Several of the cancer programs and services you’re reading about are supported by generous donors from across the Avera system. To learn how you can help support local cancer patients

through the Avera Cancer Institute, visit Avera.org and click on Avera Foundations.

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CONTENTSAVERA CANCER INSTITUTE: Many Locations, One Avera ..................................................2

WHAT’S NEW Across The System ................................................................3

GENOMIC MEDICINE At Avera Cancer Institute .......................................................4

AVERA’S PARTNERS IN GENOMIC MEDICINE .......................................8

IN MEMORY OF COACH Coach and Carmen Meyer Leave a Lasting Legacy in Aberdeen................................................10

RADIATION TECHNOLOGY TARGETS TUMORS Surgical Precision without the Incision ..................................12

MINNESOTA DAD PUTS CANCER BEHIND HIM .......................................14

GENETIC COUNSELING As a Tool in Cancer Prevention ...............................................16

ALCESTER COUPLE EXPERIENCE THE SUPPORT OF AVERA – TIMES TWO ................ 18

MAKE THE MOST OF EVERY BITE To Maintain a Healthy Weight ............................................... 21

MIND-BODY MOVEMENT REAPS Benefits of Well-Being ........................................................... 22

INTEGRATIVE THERAPIES Address Body, Mind and Spirit .............................................. 24

SPECIAL DAYS And Every Day in Between ................................................... 26

INFLUENCE YOUR OWN HEALTH FOR THE GOOD .............................................. 28

Avera Cancer Institute Summer 2014


While located at six regional centers and 40 outreach sites, the Avera Cancer Institute is one institute, dedicated to providing the best possible care, wherever patients happen to walk through the door.

“We make a brand promise that if you come to one of our sites, you will experience Avera’s approach to cancer care,” said Dave Kapaska, DO, Regional President and CEO of Avera McKennan Hospital & University Health Center, and the administrative leader of the Avera cancer service line.

Avera cancer services also are led by Michael E. Peterson, MD, Radiation Oncologist with Avera Medical Group Radiation Oncology Yankton; and David L. Elson, MD, Medical Oncologist with Avera Medical Group Oncology & Hematology Sioux Falls.

Of the five cancer centers in South Dakota that are nationally accredited through the American College of Surgeons Commission on Cancer (CoC), four are part of the Avera Cancer Institute. “For the term ‘Avera cancer care’ to mean something, it needs to be consistent,” Dr. Peterson said. “Physicians are using the best current thinking in developing care plans, and the best evidence-based treatment. Clinical guidelines and pathways are consistent throughout the organization. Patients have a seamless experience. They are treated compassionately as a human being – not a number.”

The Avera Cancer Institute concept of six regional centers means that every patient who comes to Avera for cancer care has access to the same high level of services. At some sites,

transportation and telehealth help make this possible. Avera has that capability, thanks to its reach electronically and virtually.

Justifying having cancer care equipment like the Versa HD involves having a population of 1 million. That means there can be only one of these machines in the entire system, in the name of good stewardship and best use of resources. Yet if a patient who lives in a remote location would benefit from radiosurgery for an inoperable tumor, that patient has access to this type of care through the Avera system. “It’s as simple as this: You walk into our place, you’re going to get the best,” Dr. Kapaska said.

Some health systems bring all their cancer care resources to one city or location, and ask all patients to drive to that location, regardless of where they live. This works well in a geographic area with patients who live in a 50-mile radius. Yet Avera’s service area encompasses a 250-mile radius.

“At all locations, patients have access to the technical aspects of care, and the human supportive elements of care. We personalize care for what patients need. This involves all their needs – physical, emotional and spiritual, as well as the family’s needs,” Dr. Peterson said.

Services that most people need are available through regional centers, to minimize travel as much as possible. Traveling long distances is regarded as the exception, not the rule.

CancerAveraInstitute

MANY LOCATIONS, ONE AVERA


Avera St. Mary’s Hospital in Pierre

Avera Cancer Institute Yankton

Avera Cancer Institute Marshall

Avera Cancer Institute Aberdeen

“Our brand promise to patients is that they’re getting the same high quality of care, whether they walk in the door at Aberdeen, Mitchell, Sioux Falls, Yankton and so on. Certainly it is not feasible to have all services at every location, but we’re working to ‘right size’ everything and make best use of our resources to provide care as locally as possible.”

-Dave Kapaska, DO, administrative leader of the Avera cancer service line

Fundraising has begun for a $13.5 million building project to expand Aberdeen’s cancer services. The new 25,000 square-foot building will accommodate more patients with enhanced services, including increased research and clinical trials, alternative medicine options, and more sub-specialty clinics.

A $12.95 million building will open in January 2015 to expand services, including radiation therapy for a variety of cancer types such as breast, lung, lymphomas, prostate and skin.

Lung Cancer Screening Program: Available in July, this low-dose CT screening of the chest can detect early lung cancer when it is most curable.

Breast Cancer Collaborative Registry: This registry is Avera Cancer Institute Mitchell’s first clinical trial. The database of patient health information will allow researchers to study a variety of topics such as risk factors.

Sreekanth Donepudi, MD, begins his oncology practice in Pierre in July. He will provide an important service nearby home in the diagnosis and treatment of a variety of cancers such as breast, colon, lung and prostate.

Versa HD linear accelerator: This technology, also known as radiosurgery, delivers high-dose radiation with pinpoint precision while sparing surrounding normal tissue.

PROVENGE®: For men living with advanced prostate cancer, PROVENGE® therapy is individually designed to stimulate a patient’s immune system to target prostate cancer cells.

VMAT (volumetric modulated arc therapy) uses single or multiple radiation beams that sweep in arcs around the patient. This advanced form of radiation therapy provides faster treatment delivery at an ideal dose that minimizes exposure to healthy tissues.

WHAT’S NEW ACROSS THE SYSTEM:

Avera Cancer Institute Sioux Falls

Avera Cancer Institute Mitchell

GENOMIC specialized team, coupled with Avera’s collaborative spirit, has brought genomic medicine to the Northern Plains. Before, this level of care was available only at large metropolitan national cancer centers.

Led by Brian Leyland-Jones, MB BS, PhD, Vice President of Molecular and Experimental Medicine, this team offers personalized cancer therapies to patients, based on their individual genomic profile.

“The science of medicine was transformed in 2001 with the sequencing of the first human genome,” Dr. Leyland-Jones said. The first cancer genome was sequenced in 2009. “The genome is all the genetic information contained in your DNA, and it serves as an instruction manual for every cell in your body. This book has 6 billion letters arranged in 46 chapters.”

An individual’s DNA sequence encodes what diseases he or she may be at risk for, how that person might respond to certain medications, or what medication dose would be effective with the least amount of side effects.

Cells are constantly replicating, and the body has its own repair system when something goes wrong. Cancer is when the rate or type of replicating errors exceeds the cells’ ability to repair these errors. For example, smoking just three cigarettes will cause a single genetic mutation, 30 cigarettes per day will cause 10 mutations and after one week, this becomes 70 mutations. “Repetitive exposures will bring cumulative genetic changes that are so great and so rapid that repair processes are overwhelmed,” Dr. Leyland-Jones said.

Dr. Leyland-Jones closely collaborates with Casey Williams, PharmD, BCOP, Director of Molecular and Experimental Medicine, and a highly specialized

A

AT AVERA CANCER INSTITUTEMEDICINEgenomic nursing team, seeing patients at Avera Medical Group Oncology & Hematology, located at the Avera Cancer Institute Sioux Falls.

This multidisciplinary team also includes research scientists, experts in bioinformatics, nurse practitioners and more. “We collaborate with many of the top experts in the world. Cancer patients we work with have a tumor board of around 40 people looking at their particular case,” Dr. Williams said.

The team works with patients who have all types of cancer, with a specific focus on breast cancer that has become metastatic or resistant to treatment.

Genomic medicine involves comparing the genetic sequences of

DNA in a tumor cell and a normal blood cell to identify exactly what

changes took place at the cellular level, and match targeted therapy

to these specific changes.

Patients are referred to the program by their physician or oncologist,

or patients may self-refer by contacting Avera Medical Group Oncology & Hematology at 605-322-6900.

BRIAN LEYLAND-JONES, MB BS, PHD, VICE PRESIDENT OF MOLECULAR AND EXPERIMENTAL MEDICINE

*Coverage for genomic medicine varies among insurance providers.

5Summer 2014 Avera Cancer Institute

?WHAT IS

GENOMICMEDICINE

For the past several decades, doctors have prescribed cancer treatment based on what they think will work for a particular type of cancer. “The trouble is, we commonly don’t know until several weeks or months into the treatment whether it’s working or not,” Dr. Williams said. “With genomic medicine, we can better predict up front what treatments are likely to work, or what treatments are likely not to work.”

• Specialistsreviewthepatient’shistory,andspend time visiting with the patient to provide education and determine if sequencing is the appropriate next step.

• Bloodsamplesarecollected,aswellasasample from the tumor biopsy.

• SamplesaresenttoboththeAverapathologylab and Avera’s specialized cancer genomics lab in La Jolla, Calif. This lab is located in La Jolla to be closer to collaborating experts.

• DNAisextractedfromthetumorcellandnormal cell, and then sequenced using multiple tests.

• SequencingofthetumorcellDNAiscompared to sequencing of normal DNA.

• Bioinformaticsexpertsorganizetherawsequencing data into an understandable form.

• Expertsonamultidisciplinarysequencingtumor board match specific targeted therapy to genetic changes. This tumor board makes a recommendation to Avera’s disease specific conferences.

• TheclinicalteamcollaborateswithAvera Cancer Institute oncologists to carry out the treatment plan.

• Thepatientreceivesfollow-uptesting,because tumors – desperate to survive – might evolve or change pathways.

“Right here, we are building a cancer genomic program

that rivals any other program worldwide. Regionally, there is no other cancer program

offering this level of care.”

-Brian Leyland-Jones, MB BS, PhD Vice President of Molecular and Experimental Medicine

6 Avera Cancer Institute Summer 2014

Genomic medicine programs typically exist at large national cancer centers, and Avera’s is similar in many ways. Yet Avera’s program is set apart by several factors. First, most programs use only one test, or platform, to find genomic changes. “We use multiple tests to be as precise as possible. We’re also set apart by the diversity of our team and collaborative partners, and our cutting-edge, aggressive approach to match drugs to specific genetic changes,” Dr. Williams said.

This team is committed to a 14-day turnaround time whenever possible, when most programs might take up to three months to provide answers.

“This technology will absolutely revolutionize cancer care,” Dr. Leyland-Jones said. Five years from now, it will be routine for cancer patients to have genomic testing soon after diagnosis, so treatment can be matched to the cell changes early on in the cancer care journey.

Genomic medicine is on the leading edge of cancer care, and is a preview of what standard cancer care will be like in the future.

“A well-oiled machine that flows very well.”

“We were amazed at how the complex information was brought down to our level.”

“I felt refreshing, renewed hope after my visit.”

Patient comments on Avera’s Genomic Medicine:

7Summer 2014 Avera Cancer Institute

AVERA LOCATIONSAvera Cancer Institute Aberdeen Aberdeen, S.D.

Avera Cancer Institute Marshall Marshall, Minn.

Avera Cancer Institute Mitchell Mitchell, S.D.

Avera Cancer Institute Sioux Falls Sioux Falls, S.D.

Avera Cancer Institute Yankton Yankton, S.D.

Avera St. Mary’s Hospital Pierre, S.D.

Avera’s Genomic Medicine team collaborates with a 40-member Sequencing Tumor Board comprised of experts from across the nation in clinical oncology, pharmacology, clinical genetics, genomic informatics, bioethics and pathology. The Avera team together with collaborators review sequencing results from patients. This data is then summarized, recommendations are made and then presented at Avera’s disease-specific multidisciplinary tumor boards where the final treatment recommendations are made. The actual number of participants of both tumor boards combined is more than 60 people. These results are then discussed with the patient and his or her referring physician.

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Stanford UniversityPalo Alto, Calif.

J. Craig Venter Institute,Rockville, Md.; La Jolla, Calif.

Scripps Health,San Diego, Calif.

Scripps Research,San Diego, Calif.

University of California San Diego Health System,San Diego, Calif.

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Sanford-Burnham MedicalResearch Institute,La Jolla, Calif.

George MasonUniversity, Fairfax, Va.

Carolina Center for GenomeSciences, University ofNorth Carolina

TGen (Translation GenomicsResearch Institute),Phoenix, Ariz.

CELERA,Alameda, Calif.

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Singular Bio,San Francisco, Calif.

International Breast CancerStudy Group (IBCSG), Bern, Switzerland

Theranostics Health,Rockville, Md.

Med Fusion,Lewisville, Texas

Northern Great PlainsOncology Network and Fred and Pamela BuffettCancer Center, University of Nebraska Medical Center, Omaha

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AVERA’S PARTNERS IN GENOMIC MEDICINE

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t was a beautiful late summer evening when a caravan of Northern State University men’s basketball players traveled across northeastern South Dakota, heading toward a team retreat. Suddenly the lead car, driven by head coach Don Meyer, began to drift across the center line right into the path of a fully loaded semi-truck. The impact was sudden and violent. Rushing to the vehicle, the team tried to keep the badly injured Coach Meyer conscious until the Avera St. Luke’s Careflight team arrived to transport him to the hospital in Aberdeen, and then to Avera McKennan Hospital & University Health Center in Sioux Falls.

In Sioux Falls, Coach Meyer was rushed into emergency surgery, and after several hours, his wife Carmen was relieved to learn he had survived. Yet Coach would not only have to recover from his serious injuries. Surgeons had discovered carcinoid cancer in his liver and small intestine. After learning of his diagnosis, Coach Meyer made a decision that would have a profound effect on his life. Rather than become discouraged, he would consider it a blessing that his trauma surgeon found the cancer.

COACH AND CARMEN MEYER LEAVE A LASTING LEGACY IN ABERDEEN

COACH“What’s great about this is I would not have known about the cancer had I not had the wreck,” Coach Meyer said at the time. “God has blessed me with the one thing we all need, which is truth. I can now fight with all of my ability.”

After eight surgeries and a lower leg amputation, Don and Carmen returned to Aberdeen. Under the care of Richard J. Conklin, MD, of Avera Medical Group Oncology & Hematology Aberdeen, Coach Meyer was able to continue coaching and soon surpassed Bobby Knight to become the winningest men’s coach in NCAA history – a title he would hold for two years. After four decades of coaching, Meyer retired in 2010. It was time to focus on his family, health and legacy.

Coach’s journey wasn’t easy, but he and Carmen felt fortunate to have cancer care near their home in Aberdeen. Having local access to advanced technology and state-of-the-art treatment was an enormous blessing.

Memoryof

In

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He influenced countless people through his legendary career. After his retirement, he and Carmen traveled the country giving motivational speeches and sharing their message of faith, love and hope.

For the last few years Coach and Carmen devoted a great deal of time raising awareness about the outstanding, state-of-the-art, comprehensive care they received throughout the Avera system. This included a commitment of time and resources to the capital campaign, “Avera Cancer Institute Aberdeen, Mission of Hope and Healing.”

Coach and Carmen were honored at a ceremony April 3, when it was announced that Aberdeen’s new cancer facility will be named after them. Construction for The Coach Don and Carmen Meyer Center for Excellence, home to the Avera Cancer Institute Aberdeen, is slated to begin this fall.

Although he had hoped to see the new cancer facility completed, Coach Meyer passed away on May 18, 2014, surrounded by his loving family.

Despite 923 wins as a head coach, Coach Meyer’s greatest legacy will be as a husband, father, grandfather, teacher, leader and friend.

For more information, or to donate to the Avera Cancer Institute Aberdeen, visit AveraStLukes.org

In one of his final appearances at an Avera St. Luke’s event in Aberdeen, Coach Don Meyer shared the following, “The secret of Avera is that Jesus Christ lives in these people. That is why every time you walk through those doors it’s joyful. They bring joy.”


Avera Cancer Institute is now armed with a powerful new tool in the fight against cancer: the Elekta Versa HD linear accelerator. It is specifically engineered to deliver stereotactic radiosurgery and stereotactic body radiation therapy (SRS/SBRT) delivering high dose radiation to very small targets with great precision.

The new unit in Sioux Falls is one of the first machines of its kind to be installed in the nation and was supported through a $4.2 million grant from The Leona M. and Harry B. Helmsley Charitable Trust.

“This technology, used with curative intent, involves hundreds of beams from many angles that converge on a small tumor and deliver a very high dose of radiation. The increased dose is more likely to destroy the tumor. In addition, the accuracy and precision provide greater sparing of nearby healthy tissue, with fewer side effects,” said James Simon, MD, Radiation Oncologist with Avera Medical Group Radiation Oncology Sioux Falls.

SBRT with the Versa HD increasingly is used to treat early stage lung tumors for patients unable to undergo surgery, a

JAMES SIMON, MDRADIATION ONCOLOGIST

Surgical Precision Without the Incision

NewRadiationTechnology Targets Tumors

group of patients who previously could not be treated with a curative intent. In addition, SBRT can be used to treat tumors in other areas of the body such as the spine, liver, pancreas, kidney and prostate.

“This is an exciting step forward in lung cancer treatment because in the past, people with medically inoperable lung cancer didn’t have a good option,” Dr. Simon said.


Stereotactic radiosurgery (SRS) is used to treat brain tumors – both primary brain tumors and metastatic tumors that have spread to the brain. In SRS, radiation oncologists collaborate with neurosurgeons to determine the best treatment approach for the individual patient.

The Versa HD, delivering SBRT/SRS, decreases the number of daily treatments to five or less, and dramatically reduces treatment delivery time from hours to minutes.

Patients experience the following benefits:• Reducednumberofdaily treatments to between one and five, as opposed to 25 or more

• Reducedtreatment delivery time, from hours to minutes

• Noninvasive,yetas precise as surgery for inoperable tumors

• Nopain,noincision, no anesthesia

• Fewsideeffects

• Immediatereturn to normal activities

In February, Jon Goldtrap marked a momentous occasion in his battle with Hodgkin’s lymphoma.

The 46-year-old father from Marshall, Minn., hit the five-year survivor benchmark, often used as a milestone that the patient’s cancer is less likely to recur.

“As time progresses you get more confident in, yes, it’s going to be OK, but never, ever was I to the point of being completely confident,” Jon said. “To hear that word, cured, changes your outlook dramatically. Now I don’t live under that shadow of doubt. It’s like a magical word.”

Jon, a business analyst for The Schwan Food Company in Marshall, has six kids, including one daughter who was 6 years old when he was diagnosed.

He had noticed the lymph nodes in his neck were swollen and was advised by his physician that it may be mono. When it didn’t get better in a few weeks, he went to the doctor again and had a biopsy. Days later he was at the Avera Cancer Institute Sioux Falls receiving his first chemotherapy treatment.

Hodgkin’s lymphoma is cancer of the lymphocytes, also known as white blood cells, which are the body’s primary defense against infection and disease. Hodgkin’s lymphoma can be aggressive and necessitate surgery, but Jon was able to successfully put his cancer into remission with chemotherapy and radiation.

His physician was Mark Huber, MD, with Avera Medical Group Oncology & Hematology Sioux Falls, but Jon was able to do most of his chemotherapy at the Avera Marshall Regional Medical Center. His radiation was done at a clinic in Willmar, Minn., for which he made daily trips with the help of his oldest son, Brandon.

Dr. Huber has traveled to Marshall to provide outreach services for the past eight years. The service provides patients treatment closer to home with less travel.

Puts CancerMinnesota Dad

Behind Him

Jon Goldtrap celebrated his one-year anniversary cancer free with a trip to Disney.

“I think those nurses are in some challenging situations day in and day out. They were wonderful with me. They were upbeat. They don’t ask how you feel, they know how you feel — you don’t feel good. They were more focused on, ‘hey, what’s going on in your life?’ and talking to my daughter.”

- Jon Goldtrap


“It’s hard enough to be taking chemotherapy, or feeling sick or ill with cancer, and then have to travel long distances,” Dr. Huber said.

Jon credits his family, particularly his wife, for providing support and taking care of life’s details so he could focus on his treatment.

“I really tried to stay as close to my normal routine and have a positive outlook on things,” he said. “I still worked what little I could to help occupy my time so I didn’t think about it.”

During chemotherapy treatments, Jon got to know the Marshall staff and was even moved to write a poem about the care he received.

Minnesota Dad

For those who enter through the doorTake comfort and fear cancer no more

The team within these walls is the bestThey will help put your fears to rest

Trust in their tried and true waysAnd soon they will amaze

For all the souls they nurse throughWe say to these Angels “Thank You”

A PoemJon Goldtrap

Jon Goldtrap, left, is pictured with his wife and five of his six children halfway through his chemotherapy treatments. Pictured in the back row, left to right, are Jon, Brandon, Amanda, Cassey and Christy. In the front row are Abbey and Nathaniel.

Through physician visits and Avera eConsult telemedicine connections, the Avera Cancer Institute provides outreach care in 40 communities throughout South Dakota, Iowa, Minnesota and Nebraska.

Avera’s outreach program allows the extension of specialty care across Avera’s 71,000-square-mile footprint. Cancer specialists, as well as numerous other medical specialists, are available to patients in person or through telemedicine. Outreach allows patients to stay in their own community, in familiar surroundings near family and friends.

For example, Heidi McKean, MD, Medical Oncologist with Avera Medical Group Oncology & Hematology, travels to Pierre once a month and devotes an entire day each month to Avera eConsult visits. “I really feel the patients I see at outreach locations are my patients – and they get to sleep in their own bed at night.”

by

CANCER OUTREACH SERVICES

HEIDI MCKEAN, MDMEDICAL ONCOLOGIST


These questions often can be answered through genetic counseling and testing. Kayla York, MS, LCGC, is a Certified Genetic Counselor with the Avera Cancer Institute Sioux Falls.

Among patients diagnosed with cancer, she often sees those who have a strong family history of cancer, those who are under age 50 at the time of their diagnosis, or those patients who have had more than one type of cancer. She also sees family members of patients with cancer. Individuals can be referred by a physician, or can self-refer.

Richard Conklin, MD, Medical Oncologist with Avera Cancer Institute Aberdeen, said he often refers patients for genetic counseling who might carry a mutation of the BRCA1 or BRCA2 genes, causing a higher risk of breast and ovarian cancer; a gene mutation for Lynch syndrome, which predisposes

people to colon and endometrial cancer; and genes that contribute to other more rare types of cancer, including pancreatic and kidney.

The first step of genetic counseling is simply a conversation about family history and genetics. An estimated 5 to 10 percent of cancers are inherited. “We draw out a family history, and try to determine what the chances are that we would see a genetic mutation in a particular patient,” York said.

If the personal and family history indicates a possibility of a genetic link, York then discusses the pros and cons of genetic testing with the patient and family. “Not everyone wants to know. For some people, knowing that there’s a genetic link would cause more anxiety. Yet for others, they can take that information and use it to be more proactive through increased cancer screenings or additional surgeries.”

The types of genetic testing that are available are ever expanding. Some of the more common tests include testing for the BRCA and Lynch syndrome genes. “We have 20,000 genes in our cells. We now have testing that can look at multiple genes at one time,” York said.

AS A TOOL IN CANCER PREVENTION

GENETICCOUNSELING

When patients are diagnosed with cancer, they often wonder about their children’s risk, as well as their own future risk, for cancer.

RICHARD CONKLIN, MDMEDICAL ONCOLOGIST

KAYLA YORK, MS, LCGCCERTIFIED GENETIC COUNSELOR


Genetic testing can benefit patients by confirming the need to proactively prevent and screen for cancer, or reduce the need for more extensive screening.

For example, if a patient tests positive for Lynch syndrome, his or her children can in turn decide if they want to be tested. “The children would have a 50 percent chance of carrying the gene change,” York said. If a Lynch syndrome gene change is present, the person has up to an 80 percent chance of developing colon cancer during his or her lifetime, and females have up to a 60 percent chance of developing endometrial cancer.

If children choose to be tested and test positive, they can opt to have earlier cancer screenings, for example, colonoscopies every one to two years beginning at age 25, instead of the recommended colonoscopy every 10 years beginning at age 50.

Likewise with a BRCA gene, women who test positive after a breast cancer diagnosis can use that information to decide whether or not they would go ahead with additional surgery to prevent future breast or ovarian cancer. Children of a BRCA-positive patient can be tested, and women can decide if they wish to have surgery to prevent breast or ovarian cancer, or to begin screenings at an earlier age. With women

who are BRCA-positive, MRI screening beginning at age 25 is recommended, instead of yearly screening mammograms beginning at age 40.

In addition to referring today’s patients, Dr. Conklin is also going back in past records to identify patients treated in the last two decades who meet criteria to be tested. “It’s extremely valuable, for both patients and their family members,” he said.

Many insurance plans cover genetic testing, if the counseling assessment indicates a need for it. Patients who have genetic mutations that are associated with cancer cannot be discriminated against or have their health insurance coverage reduced, thanks to provisions of the Genetic Information Non-Discrimination Act (GINA) of 2008.

“Genetic testing allows us to use science to help us determine how we can better prevent cancer or catch it in its earliest stages,” York said.

An Alcester, S.D., couple not only share similar names and a history of 42 years together. They share the life-changing experience of cancer.

Bobette Anderson was diagnosed with breast cancer in 2007. “I had been watching a lump under my arm,” she said. The lump did not appear on mammograms or ultrasound. “But finally I had a biopsy and there it was.” Bobette underwent eight rounds of chemotherapy, bilateral mastectomy and then radiation. Today, she’s a seven-year cancer survivor.

Robert Anderson, who goes by Bob, was diagnosed with multiple myeloma in 2010 after seeking medical care for severe back pain. He had intensive chemotherapy coupled with a bone marrow transplant, which effectively put the disease in remission.

Alcester Couple

Support of Avera Experience the


Support of Avera

Two cancer diagnoses within three years would be difficult for any family. Yet the Andersons said their journey was made easier by the support of Avera, as well as their family and friends. They have two daughters and four grandchildren.

“Words can’t begin to describe how you feel – it’s like being wrapped in this big blanket of caring. There’s love all around you,” Bob said.

–Times Two

A cancer diagnosis affects a person’s entire being, as well as the patient’s loved ones. Avera cares for the whole person – body, mind and spirit.

Avera’s spiritual foundations, laid by the Benedictine and Presentation Sisters, are the bedrock for the Avera values of compassion, hospitality and stewardship. These values are lived out by numerous caregivers in differing roles: Physicians, care staff, chaplains, social workers, patient advocates, navigators and more.

Support groups provide patients and their loved ones with the opportunity to gather with others who understand, and come away empowered and informed. Survivorship programs enable patients to take additional steps toward health and wholeness.

Day-to-day interactions that would be considered secular at many institutions are sacred at Avera. From physicians to nurses, therapists, receptionists and support staff, the people at Avera care. They care enough to say a word of encouragement, to give a hug or to say a prayer.

SUPPORTIVE SERVICES

When Bob was in the hospital for his transplant, he looked forward to a chaplain’s visit every day. “One day, the chaplain could not come, and I asked one of the nurses about it,” Bob related. That same nurse came in just a short time later and read some Bible verses and prayed with Bob. “It was wonderful. I thought, wow, this is a special place.”

Bob also remembers a morning during his hospital stay when a lady came by his room to ask if he’d like a newspaper. “She was so concerned about how things were going. I asked who that was, and the nurse told me it was Sr. Mary Thomas, the Senior Vice President of Mission. I thought that she must have had more important things to do than bring me a newspaper, but I spent five minutes with her and felt so much better. It’s just that personal touch.”

“The nurses acted as if they truly cared. They were friendly, happy, positive people. When I was in the hospital, chaplains came in daily and visited and prayed with me, and that was a comfort, too,” Bobette said.

Because of his wife’s positive experience with cancer care, Bob says he was less fearful at his diagnosis. “I actually was glad to find out what it was, because I was so miserable with my back pain. When Dr. Kelly (McCaul) came in to talk to me about my diagnosis, I said, ‘OK, let’s get started.’ I had all the confidence in the world.” In fact, Bob started chemotherapy at 9 p.m. the very same day he was diagnosed.

“We both just had the feeling that we were in great hands,” Bob said.


During cancer treatment, make every bite count. That’s the advice of Nicole Haberer, Assistant Director of Nutrition Services at Avera Cancer Institute Yankton, who also is a Registered Dietitian and Licensed Nutritionist.

Cancer treatment can have a number of side effects that impact appetite, such as dry mouth, nausea, mouth sores, a change in palate, painful swallowing and more. “From the moment of diagnosis, cancer can just wipe out a patient’s appetite,” Haberer said.

Haberer provides dietary support to patients with cancer with a goal of maintaining weight and hydration. This can become especially difficult depending on the location of radiation and the type of chemotherapy. Patients tend to have the most difficulties

during radiation treatment if the therapy involves their esophagus or gastrointestinal tract. If chemotherapy is also part of treatment, there are other side effects as well.

A diet during cancer care focuses on high-protein, high-calorie foods. This may seem contrary for those already on special diets for diabetes or heart disease, yet it’s only for a short period of time.

Protein or milk powders, milkshakes, eggs, mashed potatoes, whole milk, cheese, Greek yogurt or even drinks like Ensure®, Boost® or Carnation® Instant Breakfast help increase calories and protein.

If swallowing is difficult, easy-to-eat, soft food such as milkshakes, mashed potatoes, soups and smoothies are just a few options.

MAKE THE MOST OF

EVERY BITE HEALTHY WEIGHT

TO MAINTAIN A

“We really just try to

make the most out of

every single bite. It’s not

about asking patients

to eat more, it’s about

capitalizing on everything

that they take in.”

- Nicole Haberer, RD

To make things easy, select foods that are “heat and serve” or easy to prepare. Haberer works with patients to make meals appetizing and presentable.

Hydration also can be a concern, so drink plenty of water. Avoid anything with caffeine, Haberer said. Instead, for a change from plain water, drink flavored water or add lemon slices. Gatorade® or Crystal Light® also are OK.

Research shows that maintaining a healthy weight during treatment improves outcomes. “If patients start losing weight, they are less likely to respond well to treatment. Weight loss can deplete energy and nutrient stores.” On the other hand, the right foods along with a healthy lifestyle can help patients feel more energized.

MIND-BODY MOVEMENT REAPS BENEFITS OF WELL-BEINGKeep moving! This is great advice for people of any age interested in health and wholeness – including people in treatment and survivorship phases of cancer care.


Sometimes, a bridge is needed between a time of illness and a time of more intense activity. Also, gentle movement can be just what the doctor ordered to relieve stress and anxiety, improve sleep and promote relaxation.

“Movement restores energy. This is just the opposite of what we used to think – that people should just stay in bed during an illness, after surgery or after having a baby. Now, we know that people have more energy and experience a faster recovery if they keep moving,” said Dawn Flickema, MD, with Avera Medical Group Integrative Medicine.

The mind-body movement programs of Avera Medical Group Integrative Medicine are designed for all levels of physical ability. “This is meant to be a beginners’ program. Others are in the same boat, and there’s a social connectedness among people who are going through the same thing,” said Marcia Jones, Integrative Medicine Supervisor at Avera Cancer Institute Sioux Falls.

Movement instructors, several of whom are certified in cancer exercise, are trained to modify classes to meet the needs of participants. It’s also acceptable to have a chair nearby, or even be seated throughout the class, and participate as you are able.

“Mind-body movement can help patients reconnect with themselves and take back ownership of their own health. We’ve heard people express that ‘this is something I can do,’ at a time when doctors, nurses and other caregivers are doing so many things for them,” Jones said.

Mind-body movement helps people improve their mobility and regain posture or muscular balance after surgery or treatment. “People are surprised to find that after taking part in movement classes, they can stand up straight or walk without a cane,” Jones related.

Yoga: Yoga postures enhance muscle strength and flexibility, and help maintain energy and mental clarity.

Yin Yoga: Yoga poses gently stretch, soften and relax muscles and tissues.

Tai Chi:A series of gentle, continuous flowing movements are calming and relaxing, and help improve balance.

Stretch and Strengthen:These exercises help improve muscle imbalances or changes in posture that result from surgery or treatment.

Qigong:Gentle exercises involve physical postures, breathing techniques and focused intention.

Activity also is related to better outcomes. “Multiple studies have shown that patients undergoing traditional treatment have higher response and remission rates if they are active throughout their treatment,” Dr. Flickema said.

INTEGRATIVE MEDICINE OFFERS THE FOLLOWING CLASS OPTIONS:

INTEGRATIVE THERAPIES ADDRESS BODY, MIND AND SPIRIT

“Integrative therapies address everything from diet and exercise to Eastern approaches like acupuncture and Chinese herbal therapies. Our goal is not only to help people feel better during and after cancer treatment, but also to improve health outcomes,” said Dr. Williams.

The decision to try integrative therapies – and to what extent – is entirely up to the patient.

DAWN FLICKEMA, MDINTEGRATIVE MEDICINE

SALLY WILLIAMS, DOINTEGRATIVE MEDICINE

“Many people want to find that magic bullet, when the answer lies in a balance of multiple approaches for general health,” Dr. Flickema said. “Some people are looking for help in dealing with one side effect, while others are looking for an approach that supports their entire system.”

People with cancer often focus on that one part of the body or body system impacted by their disease. Yet caring for your entire person – body, mind and spirit – is as important as ever throughout the cancer journey.

Dawn Flickema, MD, and Sally Williams, DO, of Avera Medical Group Integrative Medicine provide consultations to help patients discover how they might benefit from integrative therapies.


Integrative medicine options at Avera include diet and nutrition counseling, mind-body movement, massage, aromatherapy, acupuncture, herbs and supplements including Chinese herb therapy, and art and music therapy.

Diet and nutrition is often a first concern of cancer patients. They want to understand how what they eat impacts their disease process, and how they can change their diet to improve their health. Also, those who will be undergoing chemotherapy often want to know how they can best manage their diet in order to prevent weight loss.

“The concept that the gut is the ‘second brain’ is gaining greater acceptance,” Dr. Flickema said. “It’s becoming widely accepted that what you eat affects all body systems.” For example, foods that are highly processed and high in sugar and saturated fat contribute to inflammation, which in turn contributes to poorer outcomes. “Chronic inflammation at the cellular level is thought to be a root cause of illness,” Dr. Flickema added.

Acupuncture is a therapy often recommended to address various symptoms and side effects of cancer treatment including pain, nausea and neuropathy, marked by numbness, tingling or burning in the hands, arms, feet and legs. Massage is also effective in addressing neuropathy.

Yet overall, acupuncture also can boost energy levels and immune function. Chinese herbal therapy works in similar ways to acupuncture by maintaining healthy flow of energy throughout the body. Chinese herbal therapy can address specific symptoms, and also help patients regain balance and strengthen the body’s resistance to disease.

Aromatherapy is popular with patients, because it’s a tangible item they can touch, see and of course, smell. They can breathe in the therapeutic scents of lavender, ginger, peppermint, frankincense and mandarin to relieve anxiety, insomnia, pain or nausea. Unlike systemic drugs, patients can never get too much of a good thing. They can pick up a bottle of essential oils any time, day or night, and benefit from its effects.

Art and music therapy provides expressive ways for patients to have a pleasant diversion. Examples include making jewelry during chemotherapy, or hearing a favorite song during a music therapy session.

“Integrative therapies are not meant to replace traditional cancer care. Yet they can help make traditional cancer care more tolerable,” Dr. Flickema said. “After cancer care, integrative therapies can support the patient in a whole new phase of health and wellness.”

While the development and growth of cancer is much more complex than diet, sugary foods are known to “feed” estrogen-related cancers, including breast or endometrial cancers, Dr. Williams said.


ince her diagnosis of leukemia in December 2009, Teresa Binkley of Brookings, S.D., has been able to be part of several joyous occasions – the weddings of her two children and the birth of her first grandchild – thanks to a successful stem cell transplant.

At age 49, Teresa, a research associate and assistant professor at South Dakota State University, sought answers when she was feeling especially fatigued around the Christmas season. A complete blood count revealed that Teresa’s white cell count was 119,000. With experience as a lab technician, Teresa knew at that moment she had leukemia.

She was referred to Vinod Parameswaran, MD, with Avera Medical Group Hematology & Bone Marrow Transplant. “I confirmed a diagnosis of acute myeloid leukemia. Teresa was started on chemotherapy, and we began the search for a stem cell donor,” Dr. Parameswaran said.

Teresa’s siblings were tested, but none was a 10-for-10 match. In the meantime, chemotherapy was keeping Teresa in remission. “By May, I was back to work, and I was feeling back to normal by Christmas of 2010,” Teresa said.

VINOD PARAMESWARAN, MDHEMATOLOGY & BONE MARROW TRANSPLANT

STeresa Binkley is thankful to have been able to attend special occasions like her daughter’s wedding in the fall of 2012. Pictured, from left, in back, Mark and Teresa Binkley; their daughter-in-law and son, Eileen and Steve, and in front, daughter Laura and son-in-law Olivier.

Mark Binkley enjoys a moment with their first grandson, Linus.

SpecialDaysAND EVERY DAY

IN BETWEEN

Thousands of Americans each year are diagnosed with life-threatening diseases for which bone marrow transplantation may be the best – and only – hope for a cure.

Avera Transplant Institute in partnership with the Avera Cancer Institute has offered the region’s only bone marrow transplant program since 1996.

For diseases such as leukemia, lymphoma, multiple myeloma and more, bone marrow transplantation offers the best chance for survival by replacing malfunctioning blood-forming stem cells found in the patient’s bone marrow.

“Once only offered at large metropolitan areas, now those in Sioux Falls can get the very same level of care, right next door, or at least closer to home with the compassionate, personalized care that characterizes Avera. It gives people real hope,” said Kelly McCaul, MD, Hematologist with Avera Medical Group Hematology & Bone Marrow Transplant.

“Whether you live a month or two years after a bone marrow transplant, every day holds something to be thankful for.” -Teresa Binkley

Yet in April 2011, Teresa relapsed, and by then, Be the Match had identified an unrelated 10-for-10 match through a universal donor database. “It was time to schedule a stem cell transplant as the best possible treatment for long-term survival,” Dr. Parameswaran said.

Teresa was well enough to attend her son Steve’s wedding before having her transplant June 29.

“The transplant went well, although I had some complications, including graft versus host syndrome.” Throughout 2011, Teresa spent 117 days in the hospital. “It was a long, long healing.” Yet by Thanksgiving, she was home with her family. “Since, I’ve been quite well.” Teresa says her husband, Mark, an academic adviser at SDSU, probably spent 115 of the 117 days (and nights) in the hospital with her. “He is the love of my life, and was a constant caregiver,” she said.

Their daughter, Laura, was married in the fall of 2012 to Olivier, a friend that Steve met while studying abroad in France. In December of 2012, Steve and his wife, Eileen, had their first child, Linus – the Binkleys’ first grandchild. Laura and Olivier live in New Hampshire, where they work for Dartmouth College, and Steve and Eileen are teachers in Brookings.

The donated stem cells came from Europe, where contact with donors is not allowed for two years. Teresa then wrote a letter to her donor, a 27-year-old man in Germany named Markus. “His little package of cells was shipped all the way from Germany to Sioux Falls to save my life,” Teresa says.

Today, she’s thankful that she was there for her family’s special occasions, and every day in between.

Markus, pictured in Germany with his girlfriend, donated stem cells that were shipped to Sioux Falls to save Teresa’s life.

Region’s Only Bone Marrow Transplant Program


FOR THE GOODYOUR OWN HEALTH

Want to feel great and stay well? More than anyone else, you have the power to influence your own health for the good through exercise, a healthy diet and good weight management. As a physician who is certified in family practice, I also would add annual preventive health exams to this list.

Do you have a primary care provider? If not, you should. Your primary care provider is your partner in good health who will help you manage your overall health, and is there to help when you have challenging health conditions.

Annual exams are important for everyone, but even more important for people who have had a past cancer diagnosis, or those with ongoing chronic conditions.

Your provider will work with you to ensure that you are staying current with all health screenings that are recommended for your age and gender.

More than just an item to check off the list, these health screenings save lives! Many screenings involve checking for cancer or precancerous conditions. If cancer can be caught in its earliest stages, or better yet, prevented altogether, your chances for having a good outcome are much higher.

Please take ownership of your own health, and partner with your health care practitioner to cover all the bases when it comes to recommended health screenings. You may save your own life, or the life of a loved one, and prevent the personal challenges and expense of treatment involved with a serious diagnosis.

By Tad Jacobs, DOChief Medical Officer, Avera Medical Group

INFLUENCE

Shared decision making is encouraged between you, your cancer specialist and primary care provider regarding screening and treatment of any cancer.

• Womenages50-74shouldhaveanannual mammogram every one to two years.• Womenages40-49shoulddiscusshaving mammograms every one to two years with their provider.• Womenage75andovershoulddiscuss their decision to continue screening with their provider. • Womenathighriskshouldbereferredfor genetic counseling and possibly a high-risk screening schedule.

• Women21-29yearsold: Pap screening every three years. • Women30to65yearsold: Pap screening every three years or Pap plus HPV testing every five years.• Womenover65years old: Screening may be discontinued, if a woman has had adequate screening in years past with negative results. • Afterhysterectomy:No screening is needed for women who have had the cervix removed, as well as no history of cervical cancer.

For men who decide to proceed with prostate screening:

• Menage50-74:PSA test every two to four years. Screening may also include a digital rectal exam.• PSAscreeningisnot recommended for men over age 74.• Screeningshould begin earlier for men with certain risk factors, for example, a family history of prostate cancer or African American heritage.

Beginning at age 50, both men and women should follow one of these testing schedules

Tests that find polyps and cancer• Colonoscopyevery10yearsisrecommendedformostpatientsbeginning at age 50.• Otheroptionsincludedouble-contrastbariumenema,flexible sigmoidoscopy or CT colonography (virtual colonoscopy) every five years. Colonoscopy is the “gold standard” because precancerous polyps can be detected and removed during the same procedure, virtually eliminating the chance that these polyps would develop into colorectal cancer.

Tests that primarily find cancer:• Yearlyfecaloccultbloodtest• Yearlyfecalimmunochemicaltest(FIT)everyyear The tests that are designed to find both early cancer and polyps are preferred if these tests are available to you and you are willing to have one of these more invasive tests.

Certain patients are candidates for low-dose CT screening of the chest, which offers the best chance of finding lung cancer in its earliest and most curable stages. National screening criteria are:

• Personsage55-74years,and• Currentsmokerswithasmokinghistoryofatleast 30 pack years (for example one pack/day for 30 years, two packs/day for 15 years, etc.) or• Formersmokerswithatleasta30-pack-yearsmoking history who have quit within the last 15 years

Colorectal Cancer

Breast Cancer

Prostate Cancer

Lung Cancer

Cervical Cancer

INFLUENCE

The above screening guidelines for breast, cervical and prostate cancer are recommended by Avera Medical Group. The above guidelines for colorectal and lung cancer are recommendations of the American Cancer Society.

There may come a day when you don’t have the energy

to get out of bed, when the scent of popcorn makes you

gag and your hair starts falling out in clumps. Avera Cancer

Institute’s bold approach to cancer treatment encompasses

the mind, body and spirit with gentle care and spiritual

support, so you can face those challenges as they come.

That’s cancer care done differently.

AVHE-48898-MA2314

Cancer may steal your hair, energy and immunity. We won’t let it steal your spirit.

Cancer care done differently.

To learn more, visit Avera.org/cancer

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