Published: Synapse 2014, Vol 1
Last September, Chester County Hospital turned an important page in its 122-year history. After years as an independent affiliate of Penn Medicine, the hospital joined the Penn family, becoming the University of Pennsylvania Health System's fourth regional hospital, along with the Hospital of the University of Pennsylvania (HUP), Penn Presbyterian Medical Center, and Pennsylvania Hospital.
Driving the decision were the goals to preserve Chester County Hospital's culture and build on the qualities that make it strong, while evolving to meet the changing needs and expectations of its community. In the words of hospital President and CEO Michael J. Duncan, the vision for the new relationship with Penn Medicine is to "be us, only better." Less than a year into the process, this vision is already translating into enhanced health care services for patients at Chester County Hospital. While many developments are underway, there's been significant collaboration in the hospital's Cancer Program, made possible with increased integration of Penn's specialists and resources. In particular, services for patients with lung cancer are expanding. To appreciate what this means for people of Chester County, it helps to look at recent progress in the field of lung cancer.
A Brightening Picture
Lung cancer is an aggressive cancer usually discovered after it has advanced to an incurable stage, and it is responsible for more deaths each year than breast, prostate, and colon cancers combined. But this picture is changing. Research is unlocking clues about the disease, allowing treatment advances that are improving the outlook even for patients with advanced lung cancer. For example, it's now known that each lung tumor is different, and scientists are studying lung cancer cells to identify specific driver mutations (genetic factors) that cause a tumor to grow. This information is being used to develop targeted treatments that can block these factors and shrink tumors, often with fewer side effects than occur with standard chemotherapy. Several targeted therapies for lung cancer are now available, with more being studied in clinical trials. The current standard of care is to test lung tumors for driver mutations and, if found and treatable, to tailor therapy accordingly. Vaccines to boost the body's immune response against lung cancer cells also are being tested and made available to appropriate patients in clinical trials.
At the other end of the spectrum, progress detecting lung cancer earlier is now possible with an imaging test. Screening with a yearly low-dose CT scan has been shown to decrease the risk of dying from lung cancer in people older than 55 who have a long history of smoking. It's estimated that yearly screening in such individuals would lead to lung cancer being detected at an early stage (stage I or II) in 70% of cases.,* compared to the current situation which is 57%.
When lung cancer is found early, surgery is the number one treatment, offering potential cure for patients with small, localized tumors. When appropriate, minimally invasive or lung-sparing surgical procedures can be performed. If patients aren't candidates for surgery, they may still be able to have their tumors destroyed using a highly focused form of radiation therapy called stereotactic body radiotherapy (SBRT).
As the scope of treatments expands to better address different forms of lung cancer, it's become clear that therapy must be tailored to fit the patient. Optimal management of lung cancer -- like many forms of cancer -- takes a dedicated team of specialists working together to determine the best treatment plan for each patient.
Harnessing Every Advance in Lung Cancer Care
Chester County Hospital is moving ahead on all fronts to combat lung cancer. The hospital was focused on improving the outlook for patients with lung cancer before it joined Penn Medicine. Now, it's embracing each opportunity this new relationship brings to optimize patient care and outcomes.
"Penn Medicine is a leader in lung cancer research, diagnosis, and treatment, and our goal is to make sure patients in Chester County have access to every advance possible," says Chester County Hospital Medical Oncologist Michael Costello, MD.
"Through collaboration among specialists here and at Penn hospitals, we aim to bring patients the highest level of care available, including the most progressive surgical, chemotherapy and radiation therapies and the newest targeted medicines and immunotherapies."
The following are recent developments at the hospital that are enhancing care for patients with known or suspected lung cancer.
A team approach to lung cancer is not new to Chester County hospital. For years, specialists in lung cancer evaluation, diagnosis and treatment have worked together to care for patients with lung tumors, aided by nurse navigators and other hospital staff. Now, an even more comprehensive team of specialists is involved, with the potential for highly tailored treatment.
A major addition to the team is thoracic surgeon John Kucharczuk, MD, Chief of Thoracic Surgery for the University of Pennsylvania Health System. While his home base is at the Penn Lung Center at the Perelman Center of Advanced Medicine in Philadelphia, in January Dr. Kucharczuk started seeing patients in Chester County. This allows him to directly participate in care planning for patients with lung tumors with colleagues at Chester County Hospital. He performs surgical consults, and if patients require surgery, Dr. Kucharczuk performs the procedure at HUP. He then sees patients for surgical follow up back in West Chester.
"I was involved in the care of Chester County patients with lung cancer before the integration, but now I get to work more closely with the team that was referring patients to me," says Dr. Kucharczuk. "I also get to meet patients before I see them at HUP, and -- importantly -- patients get to meet me in the comfortable and familiar environment of their local hospital."
Dr. Kucharczuk's involvement brings vast expertise and resources in thoracic oncology, which is the study and treatment of cancers of the chest (lung cancer, esophageal cancer, mesothelioma, and mediastinal malignancies). Dr. Kucharczuk -- along with medical oncologist Corey Langer, MD, and pulmonologist Steven Albelda, MD -- oversees Penn's Integrated Thoracic Oncology Program, a goal of which is to identify the best emerging treatments for lung cancer. This program now extends to Chester County Hospital, offering patients with lung cancer the same benefits whether they are seen in West Chester or downtown.
Dr. Costello says adding an experienced thoracic surgeon to the lung cancer team is a major plus for patients. "This means we're bringing the emerging standard of surgical care for thoracic oncology to our patients at Chester County Hospital."
Typically, a thoracic surgeon is available only at hospitals where there is a high volume of thoracic surgeries performed each year. About 100 patients per year are treated for lung cancer at Chester County Hospital. Another new member of the cancer team is radiation oncologist Andre Konski, MD, MBA, MA, FACR, who joined Penn Medicine in January as Chester County Hospital's Medical Director for Radiation Oncology. Dr. Konski most recently served as Chief of Radiation Oncology at the Barbara Ann Karmanos Cancer Center in Detroit, a position he held for 5 years, following 7 years of practice at Fox Chase Cancer Center. Both centers are National Cancer Institute (NCI)-designated comprehensive cancer centers.
"Dr. Konski brings tremendous clinical expertise to the Cancer Program at Chester County Hospital," says Dr. Costello. "Having a radiation oncologist who has practiced for many years at NCI comprehensive cancer centers raises the level of care we can provide and is a great benefit to our patients."
As Medical Director for Radiation Oncology, Dr. Konski leads the hospital's team of radiation oncology physicians and nurses, medical physicists, dosimetrists and radiation therapists, who plan, coordinate and administer treatments for patients undergoing radiation therapy. He also is a dedicated member of the lung cancer team, working closely with other team specialists to plan and carry out treatment for these patients. He regularly communicates with Drs. Costello and Kucharczuk, as well as other team specialists, on matters pertaining to lung cancer care.
"It's so important that different specialists come together to coordinate and personalize treatment for each patient with lung cancer," says Dr. Konski. "Our regular meetings allow us to meet a new patient together, to discuss our thoughts about appropriate care, and then determine as a group the best course of treatment. This approach ensures each patient receives precisely tailored treatment based on input from multiple specialists, not just one."
Also new is a multidisciplinary committee dedicated to thoracic cancers, which is an outgrowth of the hospital's leadership team for lung cancer. This earlier team was instrumental in launching Chester County Hospital's Lung Cancer Screening Program in mid-2012. The new multidisciplinary committee includes specialists in medical oncology, radiation oncology, thoracic surgery, pulmonary medicine, radiology, pathology, nursing, respiratory therapy, and clinical research -- among others.
The committee meets monthly for a formal exchange of information. "Every other month we discuss programmatic decisions we're making," says Dr. Costello, who is committee chair. "For example, we look at how our lung cancer screening program is doing, whether there are clinical trials we should get involved in, if they're any opportunities to enhance patient care, or if we can be doing anything better as a team."
Dr. Costello says on alternate months the committee discusses specific patient cases. These discussions serve many purposes, one of which is to educate members of the committee as well as others in the health system. For example, primary care physicians are invited to attend so they can learn about the care and treatment options for patients with lung cancer.
"These meetings allow the whole team to participate and learn from the interactive discussions," says Cindy Brockway, RN, MSN, Director of Research and Oncology Navigation at the hospital. "They raise the level of knowledge and expertise of everyone involved in treating and caring for patients."
Brockway plays many roles in supporting the physicians and other providers who are directly involved in patient care, but she was never involved with the treatment decision process until she was brought into the multidisciplinary committee. "At the meetings, I hear what each physician is thinking and what treatment options are being considered by the group, which is extremely valuable."
Resources and Services
As a founding member of the Penn Cancer Network, Chester County Hospital has had a cancer care partnership with Penn for decades, which provides patients access to specialized services available at Penn's Abramson Cancer Center and Perelman Center for Advanced Medicine. A goal for the hospital's new relationship with Penn is to expand this strategic partnership by maximizing the strengths of each partner, streamlining access to services, and fostering greater collaboration in cancer care.
"Our new relationship allows each of us at our respective locations to leverage what we do best, and overall that's better for patients and their families," says Dr. Kucharczuk. He notes that patients with lung cancer experience many episodes of care, some of which are best managed locally, in a familiar health care environment. However, surgery for lung cancer is best performed at a hospital where the volume of thoracic surgeries are high, such as HUP.
"If a patient needs surgery, HUP has the infrastructure in place to allow me to perform the most advanced lung operations available today -- effectively and efficiently," says Dr. Kucharczuk. "That's not something I do alone. It's something the resources entrusted to me make possible, and we can use those resources to benefit patients who otherwise are best cared for at Chester County Hospital."
Since Dr. Kucharczuk joined the team, the care process for patients needing lung surgery has been made as streamlined and convenient as possible for patients. Rather than go to Penn three times, as before, patients only go in to HUP for their operation.
But the new relationship with Penn Medicine is impacting more than just the surgical care of patients with lung cancer. It's increasing utilization of Penn's breadth of cancer resources and services. Rather than try to duplicate these at Chester County Hospital, the goal is to enhance access to Penn's clinical expertise, advanced diagnostic tools, and cutting-edge treatments to give patients every benefit afforded by the Penn health system.
Dr. Costello appreciates having a direct line to Penn's team of lung cancer specialists for consultation on challenging cases. "Difficult cases can be presented at Penn's weekly multidisciplinary lung cancer conference if there's a question that needs a more comprehensive consideration of what to do," he says. "It's a great resource for our patients."
He says another great resource is Penn's Center for Personalized Diagnostics, which offers a program for analyzing lung tumors for driver mutations. "This lets us test a patient's tumor for a wide range of molecular targets and gives us an incredible breadth of knowledge about what may be driving that person's cancer," adds Dr. Costello.
Dr. Kucharczuk submits every lung tumor for analysis. "If it shows a molecular abnormality we can target this with an available therapy that can be included in the patient's treatment plan," he says. All currently approved targeted therapies for lung cancer are available at Chester County Hospital.
As the relationship with Penn matures and the two cancer programs continue to align, patients at Chester County Hospital should have increasing access to clinical trials of the latest cancer treatments. A trial of a vaccine therapy is already available to patients who qualify for the study after surgery for lung cancer, but patients need to go to Penn to receive the vaccine. A goal is to bring emerging chemotherapies, including new targeted molecular therapies and immunotherapies, and cutting-edge radiation therapies to patients in Chester County without the need to travel downtown.
Chester County Hospital is committed to keeping pace with new technology that can make a difference in patient care. One area of cancer care that is particularly "tech heavy" is radiation therapy, which relies on sophisticated technologies to effectively target tumors while sparing nearby healthy tissues. Radiation therapy plays a critical role in the treatment of many types of cancer, including lung cancer.
In 2013, Chester County Hospital acquired the TrueBeam™ system, which is an advanced tool for delivering high doses of radiation with extreme precision and speed. These capabilities allow for shorter treatment times, but they also create new opportunities to fight cancer with radiation.
One example relevant to lung cancer is the use of TrueBeam to deliver SBRT (stereotactic body radiotherapy). Unlike standard radiation therapy, which is given in small doses each day for several weeks, SBRT uses highly focused beams of high-dose radiation and is given in 1 to 5 treatments.
"SBRT offers us the ability to destroy certain small lung tumors when surgery is not an option for treatment," says Dr. Konski. He says the size and location of a lung tumor are important factors in considering whether SBRT is appropriate treatment for a patient. Dr. Konski estimates that SBRT will be available at Chester County Hospital by the end of 2014.
This June, the radiation oncology department added more sophisticated treatment planning equipment, says Dr. Konski, in the form of an advanced computed tomography (CT) scanner. "This equipment gives us better images and a better ability to target tumors and spare normal tissue," he says. Precise treatment planning ensures that a patient's course of radiation therapy is carried out in the most effective and safe way possible.
As Dr. Kucharczuk points out, the new relationship between Chester County Hospital and Penn Medicine encourages everyone involved in patient care at both locations to build on the strengths of each program. One of Chester County Hospital's strengths in lung cancer care is the ability of its team to move quickly to see patients with suspected or newly diagnosed lung cancer and to gather all the information needed to move ahead with a personalized plan of care. A key factor in making this possible is the behind-the-scenes work of lung nurse navigator Danielle Dambro, BSN, RN.
"The biggest difficulty for these patients is anxiety about the unknown," says Dr. Kucharczuk. "At Chester County Hospital, we can see a patient quickly, and if that person needs to see other specialists or have additional tests, Danielle can make it happen that day or within a few days." With efficient nurse navigation, the time from when a patient is first seen until the patient has a plan of care is short. "And it's amazing how empowering that is," says Dr. Kucharczuk. "Suddenly the anxiety starts to dissipate. The patient and family know what they're up against, and they get a plan to attack it. And quite frankly, that gets lost at bigger institutions."
Chester County Hospital has had a nurse navigator program in place for many years. Since the hospital's integration with Penn, the navigator role has intensified to ensure that all necessary clinical services are well coordinated and that patients receive the support they need.
"It's all about what's best for the patient," says Dambro. "There are lots of moving parts now, and I work closely with all members of the team at Chester County and at Penn to make sure patients get the care and services they need."
Dambro stresses that the multidisciplinary team is the key to everything being streamlined. She says, "Everyone on the team needs to be integrated with one another for the best approach to patient care."
With the full strength of Penn Medicine behind it, the lung cancer team at Chester County Hospital is more determined than ever to provide leading-edge treatment in the most caring environment possible.
"It's important for patients with newly discovered lung tumors to know they have many options and to get into a care environment where they can learn about those options and prepare to move forward," says Dr. Kucharczuk. "At Chester County Hospital, that's what we do, and we do it very well."
By Debra Dreger
Photos: Members of the Lung Cancer Committee
*Source: de Koning HJ, Meza R, Plevritis SK, et al. Benefits and harms of computed tomography lung cancer screening strategies: a comparative modeling study for the USPSTF. Ann Intern Med 2014;160(5):311-20. (Using only NLST data, 57% of cancers are detected at stage I/II.)