Tag Archives: gastric cancer

8 Strategies to Help Gastric Cancer Patients Cope with Nutrition Problems During Treatment

ACCC’s Improving Care in Gastric/GE Junction Cancer project seeks to better the quality of care for gastric and GE cancer patients treated at community cancer programs. This guest post by Colleen Gill, MS, RD, CSO, is the final blog in a series on gastric and GE junction cancers. Colleen Gill is outpatient dietitian at the University of Colorado Cancer Center, and she serves on the Advisory Committee for ACCC’s Improving Care in Gastric/GE Junction Cancer initiative.

Gastric-GE JunctionBy Colleen Gill, MS, RD, CSO

More than 70 percent of patients with gastric cancer develop malnutrition, depleting muscle mass, slowing healing, and limiting the immune system.

The growth of any tumor within the stomach will limit intake and create problems with the digestion of food. Unfortunately, diagnosis of gastric cancer may be delayed due to symptoms—such as feeling extremely full after small amounts of food and abdominal pain or heartburn—that may be attributed to more common causes. As a result, malnutrition in gastric cancer patients can begin early. Nausea and vomiting are inevitable when there is tumor blocking either the gastro-esophageal junction or gastric outlet. Fatigue can result from iron deficiency anemia due to problems with iron absorption.

Patients with gastric cancer may undergo a combination of chemotherapy and radiation prior to surgery, and may be given adjuvant therapy after surgery as well. Treatment side effects may include inflammation, pain, nausea, and vomiting which can further affect a patient’s ability to eat and maintain weight.

Here are 8 strategies that may help the patient eat better, avoid excess loss of weight and muscle, and stay on treatment:

  • Schedule 5 – 6 times to eat each day. Because stomach capacity is reduced due to tumor and/or surgery, patients can try eating smaller amounts of food at intervals during the day. Scheduling a cell phone reminder to eat can be helpful. Without some type of reminder to eat every two and one-half to three hours, patients can easily miss these opportunities, and limited stomach capacity makes it impossible to make up their calorie intake at a later meal.
  • Choose softer foods. The stomach usually breaks down solid foods into smaller pieces through muscular contractions and acid secretion, but both functions may be limited by the cancer. Consider foods that are pre-processed, like shredded meats, and canned or cooked fruits and vegetables. Take advantage of foods that are already in soft “pureed” texture, like fish, refried beans, most dairy products, eggs, mashed potatoes, winter squash.
  • Make it slick. Moist foods, or those with gravies and sauces, spread taste through the mouth, increasing palatability. These foods also slide down more easily.
  • Make it easy. There are many prepared foods that will work for you, so tour the aisles of the grocery store with your goals in mind. Frozen/prepared pasta dishes, mini-quiches, and microwavable mashed potatoes, soups and breakfast dishes are available. Friends and family often offer their help which can be coordinated through websites like mealtrain.com or lotsofhelpinghands.com. Include liquid calories. They slip through narrow openings and are less likely to distend the walls of the stomach. Options include milk-like oral supplements, which are usually lactose free if that is a concern. Choose the “plus” versions for an extra 100 calories and higher protein levels. If milk is tolerated, many enjoy Carnation Instant Breakfast powder, stirred in, adding 130 calories. Scandishakes will add 440 calories and are well liked. Clear liquid drinks include Boost Breeze and Ensure Active, which some people also enjoy mixed with carbonated clear sodas. In the grocery store’s produce area, you’ll find fruit-based drinks such as those from Odwalla, Naked Juice, and Bolthouse that include versions with protein. All of these can be used as a base for smoothies, which should always include some source of protein.
  • Create a list. Coming up with ideas for what to eat on the spur of the moment can be stressful. Create a “go to” list of options for your refrigerator (or wallet). This can help you avoid falling back on the same things over and over, which can lead to “burning out” on particular foods. Including the “extras” that add calories on your list. These can help ensure that each bite counts. For example, add cheese when you warm up refried beans or scramble an egg, or add walnuts or peanut butter to oatmeal. Jot down ideas for days when you struggle, so you can always “go to” something from the list. Use the list when making shopping lists, so that foods are available to you when you want them.
  • Adjust your list by tolerance. Never cross something off your list until it has failed you more than twice. However, if you notice that higher fat or high fiber foods cause food to “sit” on the stomach for long periods of time, you may try lowering the content of fat/fiber in the food you eat and see if that is helpful. Journaling can help you see patterns.
  • Keep food safe. Many patients with gastric cancer will be on acid suppressive therapies or have less secretion of acid as the result of their cancer. Without acid in the stomach, you have less protection from bacterial contamination in food. Be careful to take precautions to keep food safe: avoid letting food sit at room temperature (keep it cold or hot), wash your hands frequently, and avoid cross contamination by keeping surfaces clean and using separate cutting boards for raw meats and foods that won’t be cooked. Be cautious with self-service salad bars and high-risk foods. Use leftovers within 48 hours.
  • Talk to your team about anything that is getting in the way of eating. They will have some solutions if you are having problems with nausea/vomiting, constipation, dehydration, sleeping, or anything else that is limiting your ability to eat. They can guide you about over the counter and prescription medications that may help, or schedule you for IV fluids or other procedures to deal with the problems. Waiting never resolves anything!

Read other blogs in this series here. Learn more about ACCC’s Improving Care in Gastric/GE Junction Cancer project here.

Optimal Treatment for Gastric Cancer—Two Multimodality Approaches

Gastric-GE JunctionACCC’s Improving Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE cancer patients treated at community cancer programs. This guest post on Optimal Treatment for Gastric Cancer — Two Multimodality Approaches is the fourth in a five-part blog series focused on gastric and GE junction cancers.

by Gurleen Dhami, MD; Veena Shankaran MD; Brant K. Oelschlager, MD; and Shilpen Patel, MD, FACRO

In 2013, there were approximately 21,600 cases of gastric cancers in the U.S. with 10,990 deaths. The incidence, however, is much higher worldwide, being the third most common cancer in the world and second leading cause of cancer-related death. Surgery has been the primary modality of treatment for early-stage gastric cancers. However, many gastric cancers are diagnosed at an advanced stage, leading investigators to find the optimal modality of treatment in this setting.

Two multimodality treatment approaches have been investigated in randomized clinical trials, both of which have been shown to improve survival beyond surgery alone. Perioperative chemotherapy (MAGIC trial) and postoperative chemoradiation therapy (INT 0116) have not been directly compared to each other. The findings and limitations of both key studies are discussed below.

MAGIC Trial

The landmark international phase III randomized MAGIC trial evaluated the role of perioperative chemotherapy in patients with resectable gastric cancers as well as GE junction tumors. The hope was for perioperative chemotherapy to improve the likelihood of a curative resection and to downstage the tumor at time of surgery. Five hundred and three patients with resectable gastric adenocarcinoma, GE junction, and lower esophageal cancers were randomized at the time of diagnosis to undergo either perioperative chemotherapy, entailing both pre- and post-operative chemotherapy, versus no additional treatment after surgery. Nearly three-quarters of the cases were gastric cancers. The chemotherapy arm consisted of three cycles of ECF (epirubicin, cisplatin, and 5-FU) before and after surgery. In terms of the surgical resection, the extent of lymph node dissection was determined by the surgeon. With a median follow-up of 4 years, only 42% of participants randomized to the chemotherapy arm actually completed the entire course. Despite this completion rate, patients who received perioperative chemotherapy had a statistically significant improvement in 5-year overall survival, 36% in the chemotherapy arm versus 23% in the surgery alone arm (p = 0.009). Progression-free survival also was improved in patients who underwent perioperative chemotherapy (HR 0.66, p<0.001). Additionally, perioperative chemotherapy decreased the tumor size, 3 versus 5 cm median maximal diameter at time of surgery (p<0.001), as well as increased proportion of stage T1 and T2 tumors at time of surgery (p=0.002). Postoperative complications were similar in both groups. The results of this study established that perioperative chemotherapy had superior survival outcomes in addition to shrinking the tumor at time of surgery. A major limitation of this study was the limited extent of lymph node dissection, with only 38% of patients undergoing a D2 resection. Resections were curative in 69% of the perioperative chemotherapy arm and 66% of the surgery alone arm. This stems from the design of the study as patients were randomized at time of diagnosis and prior to any treatment. Thus, approximately one-fourth of the patients actually had non-curative surgery. Another limitation of this trial was that laparoscopy to rule out occult metastasis was not required prior to randomization. Thus, disease burden could have been underestimated prior to enrollment.

INT 0116

Another hallmark study, the Macdonald trial (INT 0116), evaluated the role of postoperative treatment after a R0 resection in stage IB-IV adenocarcinoma of the stomach and GE junction tumors. Five hundred and fifty-six patients were randomized to two arms after surgery: chemoradiation therapy sandwiched with chemotherapy versus no further treatment. The treatment arm consisted of one cycle of chemotherapy (5-FU and leucovorin), followed by combined treatment of radiation to 45 Gy in 25 fractions with concurrent 5-FU and leucovorin which was then lastly followed by by two more cycles of 5 FU and leucovorin. With a median follow-up of 5 years, slightly longer than the MAGIC trial, there was a statistically significant survival advantage with postoperative treatment. Median survival increased from 27 months to 36 months with postoperative treatment (p=0.005). Three-year RFS increased from 21% in the observation arm to 48% in the adjuvant treatment arm (p=0.001). A major limitation of this study is the low rate of D2 resection with only 10% of patients having a D2 resection and with approximately half of patients with a D0 resection. Treatment toxicity was also another concern of this study with over 40% of patients in the chemoradiotherapy arm experiencing grade 3 toxic effects and approximately one-third having grade 4 toxicity. Approximately one-third did not complete treatment due to toxicity. While postoperative chemoradiotherapy has been shown to have high toxicity rates in clinical trials, this toxicity has decreased with modern methods of administering radiotherapy. A 10-year update showed that there was a persistent benefit to adjuvant chemoradiation in terms of overall survival and RFS.

Making a direct comparison between these two trials is difficult as the treatment regimen and timing differed. Both trials highlight the survival benefit of additional treatment for resected gastric cancers. Patients who received perioperative treatment in the MAGIC trial did having down-staging of their tumor with preoperative portion of treatment whereas the patients in the MacDonald trial treatment arm only received postoperative treatment. In order to be eligible for INT 0116, patients had to complete a R0 resection, as opposed to the MAGIC trial in which approximately one-quarter of patients had non-curative surgery. Worth noting is in the MAGIC study, the trial was limited by hetereogenous staging, including limited use of ultrasound for staging and the variable quality of surgery and pathology. In addition, two-year survivals in the Intergroup trial was 58% versus 48% in the MAGIC trial.

These studies do highlight the importance of a multidisciplinary approach for gastric cancers. Hopefully, future trials will be able to delineate the patient timing of adjuvant treatment for gastric cancers. Many in the oncology community are awaiting the Dutch CRITICS trial which will analyze the survival benefits of perioperative chemotherapy versus neoadjuvant chemotherapy plus adjuvant chemoradiotherapy.

The authors are all affiliated with the University of Washington and the Seattle Cancer Care Alliance.


 

References

National Comprehensive Cancer Network.  Gastric Cancer. Available at: http:www.nccn.org/professionals/physician_gls/pdf/gastric.pdf. Last accessed February 27, 2014.

Cunningham D, Allum WH, Stenning SP, et al. Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med. 2006 Jul 6;355(1):11-20.

Sasson AR. Localized gastric cancer: chemoradiation is not always needed. Gastrointest Cancer Res. 2009 Mar;3(2 Suppl):S22-5.

Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med. 2001 Sep 6;345(10):725-30.

Smalley SR, Benedetti JK, Haller DG, et al. Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection. J Clin Oncol. 2012 Jul 1;30(19):2327-33.

 

 

 

 

A Conversation on Caring for Patients with Gastric or GE Junction Cancer

Gastric-GE JunctionACCC’s Improving Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE cancer patients treated at community cancer programs. Recently, ACCCBuzz asked Gregg Shepard, MD, a community-based medical oncologist, who is serving on the project’s Advisory Committee to provide some perspective on caring for patients with gastric cancer in the community setting.

ACCCBuzz: Could you give an example of a gastric cancer patient treated in your community recently?

Dr. Shepard: I’ll give three examples. Patient A (patient names and some details have been changed to protect privacy), age 50, had been developing burning abdominal discomfort gradually over a two-year period. Endoscopy showed a non-ulcerated intestinal type carcinoma of the body of the stomach limited to the mucosa. Radiographic staging did not reveal any evidence of metastatic disease. Endoscopic ultrasound did not reveal any local lymphadenopathy. Patient A underwent endoscopic mucosal resection by an expert local community gastroenterologist.

Patient B had gastroesophageal (GE) reflux and dyspepsia (indigestion) symptoms for many years and, at age 66, had also developed difficulty swallowing. He did not have much pain. He had a 50 pack-year history of smoking cigarettes but did not drink significant amounts of alcohol. By endoscopy and clinical staging he was found to have stage IIIA gastroesophageal (GE) junction adenocarcinoma with HER2 amplification by FISH analysis. He was enrolled to a clinical trial and treated with combination chemotherapy, lapatinib, and radiation followed by a transhiatal esophagectomy. About six months later, Patient B developed retroperitoneal and abdominal lymphadenopathy consistent with recurrent metastatic disease. He started treatment as part of a clinical trial with immunotherapy and a targeted agent, and he has done well with near complete response.

Patient C, age 32, developed diffuse cramping abdominal pain and distention about two years after delivering a healthy baby. Imaging studies showed a large pelvic tumor. Surgical exploration with debulking of this tumor revealed signet ring type carcinoma with deposits involving the uterus, ovaries, and mesentery. Endoscopy revealed a diffuse infiltrative signet ring carcinoma involving the body of the stomach with HER2 amplification by FISH and an activating EGFR mutation detected by PCR. She was treated with combination chemotherapy with trastuzumab but this was poorly tolerated. She developed recurrent severe pain with intestinal obstruction from carcinomatosis requiring parenteral nutrition.

ACCCBuzz: Do we know who is likely to get gastric or esophageal cancer? In other words what is the epidemiology of these cancers and how is it changing?

Dr. Shepard: In the U.S. today, gastric cancer is indeed relatively rare compared to some other cancers such as breast, lung, and colon cancer. Over the last few years in the U.S. about 22,000 individuals were diagnosed with gastric cancer annually.

On the other hand, historically gastric cancer has been one of the most common and deadly forms of cancer worldwide. It was one of the first types of cancer documented in ancient Egyptian writings. Until the 1980s, it was the leading cause of death from cancer worldwide. In recent decades, stomach cancer has declined significantly in the Western developed countries; however, other parts of the world have seen only slight decreases in the disease. In fact, today in eastern Asia, eastern Europe, and South America, gastric cancer remains more common as a percentage of all cancers diagnosed. There are differences in terms of the typical population of patients affected by gastric cancer as well as risk factors, histology, and disease behavior between these countries and the U.S. and other Western developed countries. This becomes an important factor when evaluating published literature and treatment regimens.

In the U.S., risk factors for gastric cancer are non-white race, male sex, and older age, and these individuals typically have the intestinal type of gastric cancer affecting the distal stomach, which predominantly forms focal mass lesions without severe gastritis and atrophy. The decline of gastric cancer incidence in the U.S. has largely been due to the decline in this intestinal type of stomach cancer, while proximal cardia or GE junction adenocarcinoma has dramatically increased in younger adults. This type is associated with Barrett’s esophagus and with tobacco and alcohol use. There has also been a slight decline in the diffuse form of gastric cancer which diffusely involves the stomach with gastritis and atrophy, may have a signet ring cell appearance, has a worse prognosis, and can affect men and women of any age, including young adults. It is clear that there are several different subtypes of gastric cancer, which can be a disease that affects any age, sex, or region.

ACCCBuzz: What is a particular challenge of treating patients with gastric cancer in community centers?

Dr. Shepard: Most of the challenges arise from the fact that best practice for gastric cancer usually requires multidisciplinary cooperation. The most cited New England Journal of Medicine article about gastric cancer is the 2006 article by Cunningham et al., which showed increased survival for patients treated in a multidisciplinary fashion with perioperative chemotherapy and surgical resection, a treatment approach recommended in a majority of important publications and national guidelines. This can be difficult to achieve in real-time for patients in communities with limited numbers of providers or resources. Even in larger community cancer centers with physicians in multiple specialties, ancillary services such as nutritional support may be constrained due to limited resources and poor reimbursement—which can make it difficult for patients to access these supportive services.

ACCCBuzz: What are some new and important advances in gastric cancer treatment?

Dr. Shepard: One of the most significant findings in the last decade is the recognition that some gastric cancer is characterized by over-expression of the oncogene protein HER2. Tests for HER2 status have been well established for breast cancer. While the same methods may be used to test HER2 status for gastric cancer, the level of expression is typically lower and there is heterogeneity of expression between tumor cells in an individual patient. This has important treatment implications for patients with advanced disease. Providers should use appropriate criteria when classifying HER2 status. A Phase III randomized trial with about 600 patients published in 2010 showed modestly improved response and survival with trastuzumab and chemotherapy treatment compared to chemotherapy alone for advanced or metastatic gastric cancer. Research is ongoing about the use of similar targeted therapy in early stage disease as part of multidisciplinary treatment. We are still learning about the prognostic implications of HER2 expression in gastric cancer, which continues to have a poor prognosis overall when compared to other cancers of similar stage.

ACCCBuzz: How can the care of patients with gastric cancer be improved?

Dr. Shepard: In my opinion, community cancer center providers must become expert in the care of patients with symptomatic metastatic disease. These patients may have limited life expectancy and a high symptom burden and are often, therefore, unlikely or unable to seek care at a highly specialized tertiary center.

Ancient physicians recognized the importance of the stomach as a center of mortal well-being. They understood, as we do today, that even small alterations of gastric function can have a profound impact on our mental and physical health. Certainly we must provide the right guidance about palliative chemotherapy and other systemic therapies. In addition, we must improve our ability to provide palliation and improve quality of life. Inexplicably, many palliative interventions have been evaluated using survival or similar surrogates as outcome measures without knowing if these measures are clinically meaningful. Clinical research in terminally ill patients nearing end of life is fraught with ethical and practical complications but can be completed in a scientifically sound fashion. A recent publication by Badgwell et al. in the Journal of Palliative Medicine investigated patient-reported outcome measures of quality of life in patients with gastric obstruction, while a recent publication by Mariani et al. describes a randomized, double blind, placebo controlled trial of lanreotide microparticles to treat bowel obstruction symptoms. More needs to be learned in this area.

________________

To read about “Effective Practices in Gastric Cancer Programs” and access additional resources on ACCC’s Improving Quality Care in Gastric/GE Junction Cancer project page, click here. Next in the ACCCBuzz blog series on gastric and GE junction cancers: Optimal Treatment for Gastric Cancer—Two Multimodality Approaches.

Dreaming BIG to Cure Stomach Cancer

ACCC’s Improving Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE junction cancer patients treated at community cancer programs. This is the second post in an ACCCBuzz blog series focused on issues related to gastric and GE junction cancers.

By Guest Blogger Debbie Zelman, President and Founder, Debbie’s Dream Foundation: Curing Stomach Cancer

Debbie Zelman head shot 2014-NEWStomach (gastric) cancer is a silent killer with symptoms that are non-specific, or non-existent. Stomach cancer screenings are not available in the United States, so 80% of patients are diagnosed late at stage IV, and only 4% of stage IV gastric cancer patients live for five years after diagnosis. More than 22,000 Americans will be diagnosed this year, and rates are rising among adults aged 25-39, which is of great concern.

I know this because I was diagnosed with stage IV stomach cancer in April 2008, when I was 40 years old. I was the mother of three young children, married to a physician, and a practicing attorney with my own firm. I was healthy, didn’t smoke or drink, exercised, took vitamins, and didn’t have a family history. I had NO risk factors for stomach cancer. I thought I was doing everything right, and then I was told that I had a few weeks to live.

My first thoughts were of my children. I was scared to die and that my three-year-old daughter wouldn’t remember me, and my 10-year-old twins would go through their teen years without a mother. I immediately decided that I was NOT going to let that happen, so I began the fight of my life. I underwent very harsh chemotherapy treatments, lost my hair, got neuropathy, almost lost several nails, spent years in bed, hospitals, and doctors’ offices, and had many painful days.

However, I refused to be another statistic. Soon after I started chemotherapy, a friend connected me to another stage IV stomach cancer patient, who became a huge resource for me. I had so many questions about the cancer journey that only he could answer. The doctors, nurses and other healthcare professionals were not as knowledgeable about the stomach cancer experience as another patient with the same diagnosis as mine.

I was shocked to discover there weren’t many resources for stomach cancer, and that a new stomach cancer drug had not been developed in 30 years. How was that possible?

I realized there was a lot of work to be done to raise awareness, so I began to raise funds for stomach cancer research, and educated patients, families, and caregivers. This was the beginning of Debbie’s Dream Foundation: Curing Stomach Cancer (DDF), which was founded in April 2009 to increase awareness, funding, advocacy, and education.

As the first organization in the United States to fight stomach cancer, we have helped hundreds of patients, families and caregivers in 26 states and 12 countries. We set up the Patient Resource Education Program (PREP) so stomach cancer survivors and caregivers can be matched as mentors to other patients and caregivers with similar cancer stage, biomarker, age, gender, and region.

We host free educational symposia and webinars about stomach cancer treatment, surgery, radiation, side effect management, clinical trials, nutrition, and more, which are available on our website. Our next symposium is on April 18, 2015, and we have webinars each month. We’ve held two Capitol Hill Advocacy Days and have successfully increased federal research funding for gastric cancer by millions of dollars. Our upcoming Advocacy Day is on March 4-6, 2015. We’ve funded three Young Fellowship Awards, totaling $150,000, as these researchers will lay the foundation for future discoveries for stomach cancer treatments.

Debbie’s Dream Foundation: Curing Stomach Cancer is pleased to partner with the Association of Community Cancer Centers on its Improving Care in Gastric/GE Junction Cancers education initiative, which offers tools and resources for community cancer programs across the country.

There are plenty of opportunities to get involved in the fight against stomach cancer. Debbie’s Dream Foundation makes it easy. To learn more about Debbie’s Dream Foundation, our events, and how you can get involved, visit us at www.debbiesdream.org.

Please dream BIG with me to make the cure for stomach cancer a reality. Together we can do anything!

__________________________

To read about “Effective Practices in Gastric Cancer Programs” and access additional resources on ACCC’s Improving Care in Gastric/GE Junction Cancer project page, click here. Next in the series, perpsectives on caring for patients with gastric and GE junction cancer from a community-based provider.

Improving Care in Gastric and GE Junction Cancers

By Becky DeKay, MBA

resources-Gastric-Effective-Practices-150x202ACCC’s Improving Quality Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE junction cancer patients treated at community cancer programs.

The detection, diagnosis, and treatment of gastric and gastroesophageal junction (GEJ) cancers involves many different specialties within the multidisciplinary cancer care team—outreach and screening, nutrition, surgery, medical oncology, radiology, pathology, nursing, social work, integrative medicine, and administration.

For this project, ACCC developed a publication on Effective Practices in Gastric Cancer Programs that summarizes findings from a needs assessment survey of ACCC membership and highlights approaches to caring for patients with gastric cancer at three ACCC-member programs that are serving as Community Resource Centers for this project:

  • Curtis & Elizabeth Anderson Cancer Institute at Memorial University Medical Center, Savannah, Georgia
  • Stanford Cancer Center, Stanford, California
  • University of Colorado Hospital, University of Colorado Cancer Center, Aurora, Colorado.

Over the next few weeks, ACCCBuzz will offer a blog series focused on gastric and GE junction cancer that will present perspectives from a community-based provider caring for patients with gastric and GE junction cancer, the views of a patient advocate, practical tips for working with patients on nutritional issues related to chemotherapy and radiation therapy treatments, and a look at two recent studies addressing the issue of optimal treatment for patients with gastric and GE junction cancers.

Providers are invited to visit ACCC’s Improving Quality Care in Gastric/GE Junction Cancer project at www.accc-cancer.org/gastric for additional resources.

Learn about ACCC’s Community Resource Centers for the following less-common cancers: acute promyelocytic leukemia, chronic myeloid leukemia, multiple myeloma, myelofibrosis, pancreatic cancer.

Becky DeKay, MBA, is President of the Association of Community Cancer Centers (ACCC).